Department  of  Health and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
SERVICES  TO  PERSONS  WITH

CO-OCCURRING  MENTAL  HEALTH

AND  SUBSTANCE  ABUSE  DISORDERS

PROGRAM  DESCRIPTIONS 
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OEI-05-94-00151  OFFICE  OF INSPECTOR  GENERAL 
The  mission of the  Office of Inspector  General  (OIG),  as mandated  by Public Law 95-452, as 
amended,  is to protect  the  integrity  of the Department  of Health  and Human  Services (HHS) 
programs  as well as the health  and welfare  of beneficiaries  served  by those  programs.  This 
statutory  mission is carried  out  through  a nationwide  network  of audits,  investigations,  and 
inspections  conducted  by three  OIG  operating  components:  the  Office of Audit  Services, the 
Office of Investigations,  and the  Office of Evaluation  and Inspections.  The  OIG  also informs 
the  Secretary  of HHS  of program  and management  problems  and recommends  courses  to 
correct  them. 
OFFICE  OF AUDIT  SERVICES 
The  OIGS  Office of Audit  Services  (OAS)  provides  all auditing  services  for HHS,  either  by 
conducting  audits with its own audit  resources  or by overseeing  audit  work done  by others. 
Audits  examine  the  performance  of HHS  programs  and/or  its grantees  and contractors  in 
carrying out  their  respective  responsibilities  and are intended  to provide  independent 
assessments  of HHS  programs  and operations  in order  to reduce  waste,  abuse,  and 
mismanagement  and to promote  economy  and efficiency throughout  the Department. 
OFFICE  OF INVESTIGATIONS 
The  OIGS  Office of Investigations  (01)  conducts  criminal,  civil, and administrative 
investigations  of allegations  of wrongdoing  in HHS  programs  or to HHS  beneficiaries  and of 
unjust  enrichment  by providers.  The  investigative  efforts  of 01  lead to criminal  convictions, 
administrative  sanctions,  or civil money  penalties.  The  01  also oversees  State  Medicaid  fraud 
control  units which investigate  and prosecute  fraud  and patient  abuse  in the Medicaid  program. 
OFFICE  OF EVALUATION  AND INSPECTIONS 
The  OIGS  Office of Evaluation  and Inspections  (OEI)  conducts  short-term  management  and 
program  evaluations  (called inspections)  that  focus on issues of concern  to the  Department, 
the  Congress,  and the  public.  The  findings  and recommendations  contained  in these  inspection 
reports  generate  rapid,  accurate,  and up-to-date  information  on the  efficiency, vulnerability, 
and effectiveness  of departmental  programs. 
This report  was prepared  under  the direction  of William Moran,  the  Regional  Inspector 
General  for the  Office of Evaluation  and Inspections,  and Natalie  Coen,  Deputy  Regional 
Inspector  General,  Office of Evaluation  and Inspections,  Region  V.  Participating  in this 
project  were  the  following  people: 
Region  V  Headquarters 
Barbara  Butz  David  Wright 
Nora  Lynn 
To obtain  a copy of this report,  call the  Chicago  Regional  Office at312/353-4124.  TABLE  OF  CONTENTS

PAGE

~ODIJcrIO  W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1

PJWGRAMIXCSR OONS  .  .  .  . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4 

Residential  Programs.  . . . . . . . . . . . . . . . . .

. . . . . . ,....O  . . . . . . . . . . ..O$  .  4


Outpatient  Programs.  . . . . . . . . . . . . . . . . . . .

. . . . . . . . ..OO.+  . . . . . . . . . . .  8


Day  Treatment@artial  Hospitalization  Programs  . . . . . . . . . . . . . . . . . . . . . . . .  13


Continuous  Treatment  Team  Programs  . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . .  19


One  Other  Program..  . . . . . . . . . . . . . . . .
. . . . . . . . . ..O  . . . . . . . . .OOO..  .
 23  INTRODUCTION

PURPOSE 
Describe  30 programs  that  serve  people  with  co-occurring  mental  health  and  substance 
abuse  disorders  in a community  setting, 
BACKGROUND 
The  National  Comorbidity  Survey, a large  general  population  survey  conducted  from 
1990to  1992, found  that53  percent  ofrespondents  with alcohol  abuse  or dependence 
over  their  lifetime  also had  a mental  disorder  over  their  lifetime,  while  36 percent  had 
a lifetime  illicit drug  use  disorder.  Fifty-nine  percent  of the  respondents  with a history 
of illicit drug  abuse  or dependence  over  their  lifetime  also had  a mental  disorder  over 
their  lifetime,  and  71 percent  had  a alcohol  use disorder  over  their  lifetime.  In any 
given year,  Survey  data  reflect  that  an estimated  7.6 to 9.9 million  persons  with  co
occurring  mental  health  and  substance  abuse  (MH/SA)  disorders.l 
The  literature  strongly  emphasizes  the  heterogeneity  of this population  in terms  of 
types  of mental  disorders,  levels of involvement  with  alcohol  and  other  drugs,  and 
degree  of functioning.  People  with these  co-occurring  disorders  can be very difficult  to 
treat,  with  chronic  and  severe  medical,  social,  and  emotional  problems  and  particular 
vulnerability  to relapse.  Few receive  integrated  treatment  in a single setting,  from  a 
single  clinician  who  addresses  both  disorders  at the  same  time.  Yet  if treated  for only 
one  disorder,  response  to treatment  is likely to be  poor. 
The  broad  social  consequences  of failing to adequately  treat  this population  include 
hopelessness,  violence,  crime,  the  spread  of HIV/AIDS,  tuberculosis,  and  sexually 
transmitted  diseases,  with their  attendant  demands  on hospital  emergency  rooms  and 
the  public  welfare  and  criminal  justice  systems. 
l%u~ams  and Activities for Persons wth Co-Occuning MH/SA Dtiorders 
In the  Department  of Health  and  Human  Semites  (HHS),  the  Public  Health  Service 
funds  many  services  and  activities  relevant  to this population. 
The  Substance Abuse  and Mental Health  Services Administration  (SAMHSA)  has many 
programs  that  are  directly  or indirectly  targeted  at people  with  co-occurring  MH/SA 
disorders.  The  national  advisory  council  of SAMHSA  has  a working  group  on Services 
1  Since NCS data repect on~ the household population ages 15-54, a true picture of the magnitude of this problem 
must rejlect an additional .l  million institutional populatio~  .1 million homeless, .05 million youth age 0-14, and .4 to 
.6 million adults age 55 or ove~ for a totaI estimated 8.3 to 10.8 million individuals. 
1  grouhpaas lso
Integration  which is currently  focusing  on this issue.  A SAMHSA  work 
been  created  to address  this population. 
Two SAMHSA  service  programs  are  specifically  targeted  at people  with co-occurring 
MH/SA  disorders.  Projects  for Assistance  in Transition  from  Hopelessness  (PATH)  is 
a formula  grant  program  to States  and  territories  with a specific  legislative  mandate  to 
se~e  persons  with  co-occurring  MH/SA  disorders.  Funded  at $29 million  in Fiscal 
Year  (FY)  1994, PATH  provides  mental  health  and  other  services  to homeless 
individuals  and  at-risk  populations  that  are  severely  mentally  ill or have  co-occurring 
MH/SA  disorders.  Secondly,  a demonstration  program  for homeless  individuals  with 
co-occurring  MH/SA  disorders  is overseen  jointly  by the  Center  for Mental  Health 
Services  (CMHS)  and  the  Center  for Substance  Abuse  Treatment  (CSAT).  Sixteen 
providers  received  grants  in September  1993 totalling  $4 million  to develop  and  test 
models  of effective  assessment  and  intervention  for this population.  In the  second 
year,  several  providers  will receive  continuing  grants  to undertake  a formal  evaluation 
of their  specific  service  delivery  modalities. 
Other  SAMHSA  programs  include  the  mental  health  services  block  grant  ($278 
million  for FY  1994) and  the  substance  abuse  prevention  and  treatment  block  grant 
($1.1 billion  in FY  1994).  Nine  Access  to Community  Care  and  Effective  Services  and 
Supports  demonstration  grants  ($19.4 million)  are  testing  services  integration 
approaches  for persons  with severe  mental  illnesses  and/or  substance  abuse.  The 
Community  Support  Program  has funded  demonstration  projects  on persons  with co
occurring  MH/SA  disorders. 
Elsewhere  in HHS,  the National  Institutes of Health  fund  research  and  services 
demonstrations  through  the  National  Institutes  of Mental  Health,  Drug  Abuse,  and 
Alcohol  Abuse  and  Alcoholism.  The  Health Resources and Services Administration 
funds  the  Health  Care  for the  Homeless  Program  and  Ryan  White  programs  for 
persons  with HIV/AIDS.  The  Indian Health Service funds  services  for American 
Indians  and  Alaska  Natives.  The  Health  Care Financing Administration  funds 
Medicare  and  Medicaid  for health  care  and  related  services.  The  Social Security 
Administration  funds  the  Social  Security  Disability  Income  and  Supplemental  Security 
Income  programs. 
Outside  HHS,  the Department  of Veterans Affairs and  the Department  of Housing and 
Urban Development  (HUD)  both  deal  with this population  in their  homeless  as well as 
other  programs.  So does  the Depatiment  of Justice via the  courts,  prisons,  and jails. 
While  the  above  list of agencies  and  programs  is long, we do not  know  the  extent  to 
which  any of their  services  actually  reach  people  with co-occurring  MH/SA  disorders. 
We  did not  find national  data  on the  number  of such  clients  served  by any of these 
agencies  and  their  programs. 
2
 Scope and Methodology 
This  study follows others  we conducted  on services  to homeless  people,  especially 
those  with mental  illness  or substance  abuse,  and  community  mental  health  services. 
In those  studies,  respondents  pointed  to persons  with co-occurring  MH/SA  disorders, 
specifically,  as underserved  both  in homeless  and  traditional  semice  programs. 
This  report  is a companion  to another  report  (Services  to Persons  With  Co-occurring 
MH/SA  Disorders,  0EI-05-94-O0150)  which  describes  the  experiences  and 
perspectives  of supervisors  or managers,  and  staff who work  directly  with clients  in 
treatment-related  activities.  The  programs  are  all community-based  (as opposed  to 
inpatient)  and  were  established  specifically  to treat  people  with co-occurring  MH/SA 
disorders.  In our  early  discussions  with SAMHSA  staff, we learned  that  information 
about  front-line  workers  was of interest  and would  complement  the  programmatic 
information  coming  from  the  CSAT-CMHS  demonstration  program  mentioned  above. 
This  report  describes  the  30 programs  in which  the  71 respondents  work.  At our  exit 
conference  at SAMHSA  on the  first report,  staff expressed  interest  in learning  about 
the  programs  that  these  respondents  work  in.  Hence  we decided  to produce  this 
companion  report. 
We  identified  these  30 programs  through  references  in the  literature,  descriptions  of 
the  special  demonstration  programs  and  other  Federal  programs,  and  suggestions  from 
experts.  Almost  all of them  treat  clients  with  co-occurring  MH/SA  disorders 
exclusively,  although  a few also have  some  clients  with mental  illnesses  or substance 
abuse  problems  only. 
The  programs  are  located  in 20 States2  and  are  very diverse  both  demographically 
and  programmatically.  Twenty-five  percent  are  in metropolitan  areas  (cities  over 
500,000),  15 percent  in small  cities  or rural  areas,  and  the  rest  in medium-sized  cities. 
The  providers  running  the  programs  include  mental  health  providers,  substance  abuse 
providers,  private  non-profit  social service  agencies,  hospitals,  and  a veterans  service 
agency.  Seven  are  recipients  of CSAT-CMHS  demonstration  funds,  and  two receive 
PATH  funding. 
Though  we did not  delve  deeply  into  the  origins  of these  programs,  our  strong 
impression  is that  the  major  impetus  in their  development  was the  recognition  by key 
staff that  this segment  of their  client  population  was growing,  and  that  their  needs 
were  not  being  adequately  met  by existing services. 
We  conducted  this inspection  in accordance  with the  Standards for Inspections  issued 
by the  Presidents  Council  on Integrity  and  Efficiency. 
2 Alaskq  California  Connec~icu~Delaware, Florida  Geor@  I1h%ok,Indian~  A4issou~ Nebraskq  New York 
Ohio, Oklahom~  orego~  South Caroling  TL=w.sV, ermont, Viiiq  W~consitq and Wyoming. 
3  PROGRAM  DESCRIPTIONS

The  following  information  comes  from  discussions  with 71 managers  and  front-line 
staff who work  in 30 programs,  located  in 20 States,  designed  specifically  to serve 
persons  with co-occurring  MH/SA  disorders.  Our  primary  focus  in these  discussions 
was on respondents  experiences  and  perceptions  about  working  with clients  with co
occurring  MH/SA  disorders,  rather  than  on their  programs  per  se.  However,  in order 
to have  a context  in which  to understand  their  comments,  we asked  respondents  to 
briefly  describe  certain  aspects  of the  structure  and  operation  of their  programs. 
These  descriptions  are  best  understood  by reading  them  along  with our  companion 
report  entitled  Services to Persons  with Co-occurring  MH/SA  Disorders:  Provider 
Perspectives  (OEI-05-94-O0150),  which  presents  an analysis  of the  responses  of 
managers  and  front-line  staff to our  survey on how they  serve  this population.  The 
combination  of that  survey  analysis  and  these  descriptions  provides  as complete  a 
picture  as possible  of issues, successes,  and  problems  in the  emerging  field  of treating 
persons  with SA/MH  disorders. 
These  programs  include  residential  programs,  outpatient  programs,  day treatment  or 
partial  hospitalization  programs,  community  treatment  team  programs,  and  a single 
room  occupancy  hotel  with  a day manager  funded  by a community  mental  health 
center  (CMHC).  We  present  a general  description  of four  aspects  of each  program: 
structure,  funding,  clients,  and  services.  The  information  reflects  what  our  respondents 
told  us - and  as much  as they  told  us.  We  did not  attempt  to veri&  their  comments, 
review  program  materials,  or evaluate  these  programs  in any way.  However,  since 
little  is known  about  programs  that  work  specifically  with this population,  we believe 
that  this information  will be  of interest  to people  in the  field. 
By way of introduction,  we note  that  respondents  share  the  same  broad  goal for their 
clients,  namely  stabilization  and  a better  quality  of life.  Furthermore,  they view 
recovery  as a relative  term,  and  expect  it to occur  gradually  over  a long  period  of 
time.  What  is interesting  to see is both  the  similarities  and  the  differences  in the way 
their  programs  are  addressing  that  goal, 
Six Residential IYograms 
Residential  Program  #1 
Structure:  This  60-day program  was established  in  1994.  Located  in a large  city in 
Oklahoma,  it is run  by a small  chemical  dependence  agency  under  a subcontract  with 
a major  hospital,  Prior  to establishing  this program,  the  hospital  led  the  formation  of 
a consortium  of agencies  providing  a continuum  of services  including  detox,  inpatient, 
residential  and  aftercare  programs. 
4
 Training  andevaluation  are  both  keycomponents  ofthis  program.  Training  is 
provided  not  only for staff in the  program  itself, but  for residents  and  medical  students 
at the  universitys  College  of Medicine.  Evaluation  will be  conducted  every  quarter, 
Funding  Funding  is provided  by mental  health  and  substance  abuse  block  grant 
funds. 
Clients:  The  program  has  16 beds,  with an average  census  of 14 clients.  The  majority 
of the  26 clients  (half male,  half female,  35-40 years  old ) served  in the  first  quarter  of 
operation  experienced  depression,  with a high occurrence  of personality  disorders. 
They  abuse  alcohol,  marijuana,  or crack  cocaine,  and  polyabuse  is not  uncommon. 
Services:  Intake,  assessment,  and  referral  to this program  are  done  at the  hospital  by 
atreatment  team  comprised  of the  program  director,  a psychiatrist,  an intensive  case 
manager  from  the  residential  program,  and  a mental  illness specialist.  The  team 
reviews  each  case weekly  and  psychotropic  medications  are  provided  through  the 
hospital,  with  oversight  by the  psychiatrist. 
The  residential  program  itself provides  case  management,  individual  and  group 
counseling,  and  education  groups.3  The  agency  has  a very diversified  array  of 
chemical  dependency  services  available  to the  clients  as well.  Staff  consist  of the  case 
manager,  clinicians,  and  counselors. 
Residential  Proaam  #2 
Structure:  This  mental  health  agency,  located  in a large  city in the  East,  has  operated 
two programs  for persons  with  co-occurring  MH/SA  disorders  for  a year  and  a half -
an  18 month  residential  program  and  a continuous  treatment  team  (CTT)  which 
deliberately  targets  people  who have  failed  in another  agency  CIT.  One  person 
supervises  both  programs  and  also carries  several  clients  in a case  management 
capacity.  Each  program  has a staff  of seven  including  a clinical  supervisor,  nurse,  and 
a diverse  group  of people  conducting  case  management  and  the  other  activities  of the 
program. 
Funding  Funding  includes  State  funds  and  Federal  funds  from  a special  grant.  The 
agency  director  has done  some  formal  outcome  evaluation  of clients  with  co-occurring 
MH/SA  disorders  and would  like to continue,  but  said that  a cut  in their  Federal  grant 
has  precluded  continuing  formal  evaluation  at the  moment. 
Clients:  Federal  funding  mandates  targeting  people  of color,  women  of childbearing 
age,  and  people  at  risk for HIV  infection.  There  are  15 beds  in the  program,  and  25 
3 Wesoonlearnedthatrespondentstalkingabout >~choeducation werereferringto diff?rentthing  from C1OS.WtoS counseling 
sessio~  and from teaching rux only about mental illness but abo about mbstance abuse and other topics such as daiiy living skills 
Hencewehavechosento usethebroader term educationin this report 
5  clients  come  throughout  in a year,  Two-thirds  are  men.  Clients  are  severely  mentally 
i114;some  also have  borderline  personality  disorders. 
Semkes:  The  agency  provides  access  to a continuum  of services,  beginning  with case 
management,  through  the  continuous  treatment  team,  to which residential  clients  can 
graduate  and  remain  as long as needed.  Within  the  residential  program,  clients 
receive  medications  and  psychiatric  monitoring  along  with individual  and  group 
counseling,  and  education.  They  are  required  to attend  12-step5 meetings,  including 
some  Double  Troubleb  meetings,  daily,  They  also participate  in recreational  activities, 
which  the  agency views as important  replacements  for substance  use/abuse. 
Residential  Program  #3 
Structure:  This is a 90-day residential  program  run by a private  non-profit  (religious 
based)  social  service  agency  in Alaska.  The  agency  is substance-abuse  based  and  this 
program  is strongly  grounded  in the  12-step  philosophy.  It is staffed  by the  director, 
two alcohol  and  drug  counselors,  and  four  paraprofessional  mental  health  aides. 
Funding  Funding  includes  Salvation  Army funds  and  special  Federal  funds 
specifically  targeted  at Alaska  Natives. 
Clients:  Half  or more  of the  clients  are  Alaskan  Natives.  Two  thirds  are  male,  and 
on average,  clients  are  in their  mid-20s.  Clients  have  chronic  mental  illnesses  and 
some  from  post  traumatic  stress  disorder  due  to prior  abuse  in the  family.  They  abuse 
alcohol,  marijuana,  and  crack  cocaine. 
Semites:  Clients  with chronic  mental  illness receive  mental  health-related  services  at 
the  local  CMHC.  A psychiatrist  comes  to the  program  weekly  to monitor  medications 
for the  Alaska  Native  clients,  specifically.  The  director  reports  that  the  agency 
recently  lost a halfway  house  and  case manager  for an aftercare  program.  She  also 
said that  clients  with  personality  or mood  disorders  who are  not  connected  with either 
the  CMHC  or the  Indian  Health  Service  health  care  network  often  relapse  during 
lengthy  waits  for services  from  those  systems, 
The  residential  program  runs  12-step  study groups,  educational  groups,  and  some 
recreational  activities.  Some  clients  also attend  12-step  groups  in the  community.  The 
program  refers  a small  percentage  of clients  to the  vocational  rehabilitation  agency  in 
the  community  at the  end  of their  stay. 
4 Thesevereorchronicmentalillnessesnamed wereprimarilyschizophreniaand depression. 
5 Al~o&li~s Anonymo~  NarcohcsAnonymous, etc. 
6A  WI  of 12-stepprogram developed specificallyfor persons with dual disorders. 
6  Residential  Promam  #4 
Structure:  ~isisa23-year-old  substance  abuse  provider,  which has been  seting  the 
persons  with  co-occurring  MH/SA  disorders  in this Nebraska  city for some  5 years. 
Staff  consists  of a clinical  director,  a psychiatrist  consultant,  counselors,  nurses,  and  full 
and  part-time  recreation  therapists.  In addition  to this residential  program,  the  agency 
runs  an outpatient  program  and  a residential  program  for  adolescents  with  co
occurring  MH/SA  disorders. 
Funding  Federal  CSAT-CMHS  demonstration  funds,  State,  city and  county  funds, 
and  some  United  Way dollars,  provide  funding,  with a small  amount  of Medicaid  and 
private  reimbursement. 
Clients:  Clients  are  homeless  or at risk of hopelessness.  The  program  houses  30 
adults  and  15 youths  at a time.  Roughly  two-thirds  are  male.  Clients  are  chronically 
mentally  ill; some  have  personality  disorders.  Reportedly,  a majority  have  been 
victims  of sexual  abuse.  Substances  used  are  alcohol  and  cocaine,  including  crack. 
Reportedly  some  younger  clients  use LSD  or inhalants.  Some  adults  abuse 
amphetamines. 
Services:  This  program  was described  as a modified  therapeutic  community  with a 
long-term  approach.  Clients  may remain  for up to  1 year.  Case  managers  at the 
parent  agency  link clients  with services  needed  outside  the  agency.  Residential 
services  include  medication  management,  group  and  individual  counseling,  education, 
and  recreational  activities.  These  latter  are  a large  part  of the  program;  staff believe 
strongly  that  clients  must  learn  to use leisure  time  in a healthy  way to replace 
drug/alcohol  use. 
Residential  Prom-am  #5 
Structure:  This  2-year-old  program  located  in a large  city in California  is run by a 
private  non-profit  agency  serving veterans. 
Fundhqy  CSAT-CMHS  demonstration  funds,  Health  Care  for  the  Homeless,  HUD, 
and  the  Department  of Labor  were  all mentioned  as sources  of funding. 
Clients:  The  80 clients  are  85 percent  male  and  average  around  45 years  old.  All are 
veterans  who have  been  homeless  or are  at risk of hopelessness.  They  have  chronic 
mental  illnesses;  respondents  especially  see  depression,  anxiety,  and  post  traumatic 
stress  disorder.  Most  clients  are judged  to be  employable. 
Services  Each  client  is assigned  a case  manager  and  a counselor.  Respondents 
described  the  program  as a structured  program  built  on a social model,  with  a heavy 
focus  on peer  support,  jobs,  self-sufficiency,  and  integration  into  the  community.  The  emphasis  is on building  confidence,  self esteem,  a sense  of community,  and,  especially, 
a sober  lifestyle. 
Clients  receive  medications  through  Veterans  Administration  programs.  In-house 
activities  include  case  management,  counseling  (group  and  individual),  and  a variety  of 
education  groups.  Clients  are  required  to attend  12-step  meetings  either  on or off-site 
and  may continue  to attend  them  after  graduating  from  the  program. 
Residential  Promam  #6 
Structure:  This is a large  private  non-profit  human  service  agency  in New York  City. 
It runs  both  housing  programs  and  a day treatment  program  for people  with co
occurring  MH/SA  disorders.  The  housing  program  is about  3 years  old. 
Funding  The  program  is funded  by CSAT-CMHS  demonstration  funds;  Medicaid  and 
Medicare  reimbursement  were  also mentioned. 
Clients:  Three  hundred  of the  400 served  by this program  have  co-occurring  MH/SA 
disorders.  From  60 percent  to 80 percent  are  male  and  they  range  in age  from  30 to 
50 years  old, although  most  are  in their  30s.  Clients  are  chronically  mentally  ill; some 
have  personality  disorders.  They  use primarily  alcohol  and  crack  cocaine.  Clients  are 
homeless  or at risk of hopelessness. 
Semites:  The  housing  program  is tailored  to individual  needs  and  geared  to provide 
the  least  restrictive  living environment  possible  for clients,  for as long  as they  need  it. 
It includes  a range  of housing  from  independent  living to housing  with intensive 
support  services,  where  residence  counselors  working  in teams  make  frequent  visits to 
clients.  Clients  can participate  in the  agencys day treatment  program  for persons  with 
co-occurring  MH/SA  disorders  and,  through  its case  managers,  access  other  services 
both  in and  outside  the  agency.  Most  clients  have  a psychiatrist  or are  affiliated  with a 
hospital  or clinic for on-going  mental  health  care. 
Eight Outpatient l?ogram.r 
Outpatient  ProEram  #1 
Structure  This  5-year-old  partial  day treatment  program  is run by a large  private 
non-profit  social  service  agency  in New York  City.  The  program  operates  from  4 to 8 
pm  Monday  through  Thursday  (after-school  hours).  Clients  may remain  in the 
program  up to  18 months.  Staff include  three  social workers,  a part-time  drug  and 
alcohol  counselor,  and  a part-time  psychiatrist  consultant.  There  is a low client  to 
staff ratio. 
Because  so many  of their  clients  have  learning  disabilities,  the  agency  is now 
developing  an alternative  high school. 
8
 Funding:  Theprogram  wasstarted  with  funding  from  aspecialtask  force  tith  the 
mission  of bridging  the  gap  between  the  mental  health  and  substance  abuse  needs  of 
adolescents. 
Clients:  The  program  serves  adolescents  from  13 to  18 years  old.  Some  14 clients

(half  girls, half boys)  are  in the  program  at  a given time,  with 200 served  annually.

They  experience  a wide  range  of emotional  disturbances,  especially  emergent

schizophrenia  or depression,  and  many  come  from  families  where  there  is physical  or

sexual  abuse,  and/or  substance  abuse.  According  to the  director,  as many  as 90

percent  of the  girls have  been  sexually abused.

Services:  The  program  takes  a family systems  approach,  and  focuses  heavily  on

helping  clients  maintain  sobriety  and  complete  school.  It is a highly structured

program  that  provides  close monitoring  of psychotropic  medications,  routine  drug

screens,  individual,  group,  and  family counseling  and  education,  recreation,  and  an

Alcoholics  Anonymous  meeting  on-site  once  a week.  A major  goal  of the  program  is

to complete  a thorough  assessment  of each  client.

Outpatient  Program  #2

Structure:  This  2-year-old  program  serves  Native  &nericans  with co-occurring

MH/SA  disorders  on a rural  reservation  in Wyoming.  The  staff  consists  of a substance

abuse  counselor  and  a registered  nurse  who is Indian  and  who works  as the  case

manager  and  outreach  specialist.  Respondents  say that  having  Native  American  staff

reduces  the  potential  for cultural  clashes  between  the  Indian  clients  and  non-Indian

providers.

Funding:  The  program  receives  some  PATH  funding  for its case  management

component;  Medicaid  and  Medicare  reimbursement  are  also sources  of funding  for the

program.  Respondents  reported  that  Medicare  and  Medicaid  requirements  that

substance  abuse  counselors  have  Masters  degrees  restrict  the  programs  ability to hire

Native  Americans,  since  few Native  Americans  have  these  degrees.

Client.x  The  program  serves  six Native  American  clients  who have  co-occurring

MH/SA  disorders  from  two tribes,  almost  all of them  men  in their  40s.  Clients  have

severe  mental  illnesses  and  abuse  alcohol  (often  to self-medicate),  marijuana,  and

inhalants.  Many  have  not been  treated  for their  illnesses  until  recently.  Other

common  characteristics  are  geographic  isolation  on the  reservation,  organic  disorders,

poor  health,  and  troubled  family histories  including  alcoholism,  poverty,  and  poor

housing.

Services:  The  program  emphasizes  outreach,  The  provider  offers  education,

individual  therapy,  medication  management,  and  family counseling.  The  programs

case  manager  focuses  on establishing  social  supports  for clients.  Clients  participate  in

community  12-step  programs  and  the  program  runs  its own therapy  group,  which

9
 meets  on the  reservation.  The  agency  coordinates  its services  with  those  of the  Indian 
Health  Service  wherever  possible. 
Out~atient  Promam  #3 
Structure:  Asubstance  abuse  agency  ina  Virginia  ci~developed  this program  4 years 
ago,  The  program  runs  Monday  through  Friday,  three  hours  a day, and  lasts  from  12 
to  18 months  depending  on client.  The  program  is expanding  and  its two therapists 
will soon  become  full-time. 
Funding  County  substance  abuse  dollars  fund  the  program. 
Clients:  The  program  serves  a maximum  of 12 clients,  most  from  30 to  35 years  old. 
In addition  to chronic  mental  illness, many  clients  reportedly  also have  personality 
disorders.  Some  have  experienced  childhood  abuse.  Many  of the  women  in the 
program  are  mothers.  Clients  abuse  alcohol  and  crack.  Some  clients  are  homeless, 
but  many  live with  their  parents.  All receive  SS1 or SSDI and  Medicaid. 
Services:  Therapists  carry  six clients  each,  and  provide  education  and  individual  and 
group  therapy  in addition  to case  management.  Each  client  also has  a prima~ 
counselor  at  other  agencies  in the  mental  health  system.  Although  the  primary  focus 
of this program  is on substance  abuse,  the  goal is to help  clients  understand  both  their 
mental  illnesses  and  their  addictions  as well as to give them  the  skills and  support 
necessary  to maintain  abstinence. 
Outpatient  Prowam  #4 
Structure:  This  3-year-old  program  in Texas  is based  in a mental  health  agency  and 
targets  homeless  people  with  co-occurring  MH/SA  disorders.  The  agency  takes  a 
comprehensive  approach,  via case  management,  to meeting  many  client  needs  in the 
hope  that  they will become  more  independent  and  live in the  community.  The 
agencys homeless  services  unit  first identifies  homeless  people  with co-occurring 
MH/SA  disorders.  Case  managers  in this program  then  link those  clients  with services 
within  and  outside  the  agency  for 6 months  to a year.  After  leaving  this program, 
clients  continue  with another  case  manager  from  the  main  program  of the  agency. 
Staff  consists  of one  administrator/case  manager,  and  a case  manager.  Each  carries  15 
to 20 clients.  Under  a contract,  a psychiatrist  visits the  program  twice  a month. 
Funding  Funding  comes  from  Federal  PATH  dollars  as well as funding  from  the 
parent  agency.  Reportedly,  the  agency  cannot  bill for Medicaid  reimbursement  due  to 
its Federal  grant. 
Clients:  The  program  sexves 30 to 35 clients  at a time  (about  350 a year).  Most 
clients  are  in their  mid-20s  to mid-40s.  The  PATH  grant  requires  that  all of the 
programs  clients  be  homeless  and  chronically  mentally  ill.  Reportedly,  the  agency  is 
10  seeing  a rapid  increase  in clients  who have  organic  disorders  due  to either  heavy

substance  use  or head  injuries.  Also, many  clients  have  a childhood  histo~  of sexual

or physical  abuse.  About  one-third  of clients  receive  SS1 or Medicaid.

Services:  The  primary  emphasis  of this program  is outreach,  engagement  and  linkage.

The  needs  of clients  entering  the  program  for food,  shelter,  and  clothing  are  addressed

immediately,  and  the  program  acts as clients representative  payee  as needed.  They

then  provide  on-going  case management,  with linkage  to mental  health  services

needed,  and  substance  abuse  counseling  in house,  involving  clients family and  friends

where  possible.

Case  managers  also run  education  groups  in four  shelters.  They  tried  a specially

developed  module,  specifically  for persons  with co-occurring  MH/SA,  but  found  it was

not  useful  for homeless  people.  The  parent  agency  continues  to use the  module  in its

other  programs,  however.

Outpatient  Promam  #5

Structure:  Housed  in a substance  abuse  agency,  this 3-year-old  State  mental  health-

substance  abuse  pilot  program  seines  a rural,  eight  county  area  in Illinois.  It

emphasizes  assertive  case  management  and  provides  clients  with large  amounts  of long

term  support.

Funding:  The  program  receives  special  State  funding,  half from  the  Department  of

Mental  Health,  half from  the  Department  of Alcohol  and  Substance  Abuse.

Client.x  The  programs  30 clients  all have  co-occurring  MH/SA  disorders  and  average

30 years  old.  They  are  chronically  mentally  ill (mostly  schizophrenic)  and  use  or abuse

mainly  alcohol.  Clients  are  often  referred  to the  program  by the  State  psychiatric

hospital,  and  it is a program  requirement  that  clients  have  had  at least  three

admissions  to psychiatric  facilities  before  they  can  enter.  In addition,  most  clients  have

had  housing  problems  and  many  have  family histories  of mental  illness  and  alcohol

abuse.

Semites:  Case  managers  refer  clients  to the  local  CMHC  for mental  health  treatment.

In house,  the  program  provides  special  groups  on co-occurring  MH/SA  disorders,

detoxification  services,  and  inpatient  substance  abuse  treatment.  The  groups  are

designed  to be  less confrontational  and  more  flexible  than  traditional  substance  abuse

treatment.  For  example,  abstinence  is not  an absolute  requirement  for participation.

Outpatient  Promam  #6

Structure:  This  l-year-old  outpatient  program  in Connecticut  is run  by a CMHC

which  is the  lead  agency  for the  mental  health  agencies  in the  area.  A committee  of

community  agencies  focused  on co-occurring  MH/SA  disorders  was set up by the 
agency  several  years  ago, and  the  agency  holds  an annual  conference  on co-occurring 
11  MH/SAdisorders  (some  150people  attended  themost  recent  one).  Italsoholdsa9-
week  training  seminar  and  is developing  a resource  manual  for  staff.  The  program 
director  is a psychiatrist  with  several  years  of experience  in this field, who is also on 
the  faculty  of a major  university.  Services  are  divided  into  two components,  one  for 
persons  with  chronic  mental  illnesses  and  another  for persons  with less severe  mental 
illnesses. 
Funding  This  program  receives  Federal  funding  from  the  National  Institute  on Drug 
Abuse.  The  parent  agency  funds both  mental  health  services  and  a substance  abuse 
program. 
Clients:  Clients,  who have  chronic  mental  illnesses,  are  reportedly  mostly  in their  20s 
and  30s.  About  40 percent  are  female,  and  50 percent  are  minority.  They  have 
histories  of poor  compliance  with medications,  frequent  rehospitalizations,  legal 
problems,  and  homelessness;  a very high percentage  reportedly  have  learning 
disabilities.  All receive  SS1 and  Medicaid. 
Services:  The  agency  offers  a full continuum  of care  including  community  treatment 
teams  that  provide  case  management  and  referral,  inpatient,  outpatient,  day 
hospitalization,  and  relapse  prevention  services.  The  director  described  the  programs 
approach  to this population  as eclectic,  integrating  a wide variety  of services  into  a 
network,  with  individual  clients  referred  to services  according  to their  needs.  Those 
with  chronic  mental  illnesses  receive  services  within  the  provider  agency.  Those  with 
less severe  mental  illnesses  receive  concurrent  semices  from  this provider  and  a 
substance  abuse  provider. 
Besides  the  director,  staff include  an administrator  who has some  clinical  duties  and 
oversees  research,  and  three  people  who share  a full-time  position  and  provide 
consultation  and  training  to other  staff  at both  the  mental  health  and  substance  abuse 
agencies.  More  staff will be  hired  to carry  out  the  research  component,  which  is to 
continue  for several  years. 
Outpatient  ProQram  #7 
Structure:  This  program  has been  run  by a county  CMHC  in Illinois for 3 years.  It 
offers  intensive  case  management  on an outpatient  basis.  Staff include  a coordinator, 
two case  managers,  and  a part-time  psychiatrist.  Staff know  and work  with  each 
others  clients.  They  take  a longitudinal  view of treatment  and  care,  and  expect  clients 
to use  the  sexvice throughout  their  lives. 
Funding  The  program  is part  of a special  Statewide  program  for people  with co
occurring  MH/SA  disorders.  Funding  comes  from  the  State  mental  health  and 
substance  abuse  agencies,  and  Medicaid  reimbursement. 
Clients:  The  program  serves  40 clients.  Their  average  age is 32 and  75 percent  are 
male.  The  program  sees  clients  with schizophrenia,  primarily,  and  many  reportedly 
12  also have  personality  disorders.  Alcohol  use is primary;  clients  also  use marijuana  and 
respondents  said  that  crack  cocaine  is like a plague.  Many  clients  have  continual 
housing  problems.  They  reportedly  have  burned  down  all their  clinical  bridges 
before  coming  to this program.  About  70 percent  receive  SS1 and  Medicaid.  There  is 
a waiting  list of 30 clients. 
Semites:  The  program  uses case  management  to link clients  with community  services. 
Case  managers  each  carry  15 clients;  the  coordinator  has  a caseload  of 10.  Staff  also 
do some  group  work  such  as modified  12-step  groups  using an educational,  non-
confrontational  approach,  or education  groups. 
Outpatient  Program  #8 
Structure:  This  2-year-old  program  in California  was developed  from  a homeless 
program  for chronically  mentally  ill clients.  It is this  citys only program  for clients 
with  co-occurring  MH/SA  disorders.  Treatment  lasts for  16 weeks,  although  the  time 
limit is flexible.  Staff include  the  coordinator  (who serves  part-time  as a case 
manager),  case  managers,  a part-time  psychiatrist,  and  a full-time  therapist  position 
-l. 
ML.l.t u  --Ala!  1U-.. y LL.. wu-   M:--l:..:l ulvluA.u. tlls. 
Funding:  Funding  includes  Medicaid  reimbursement  and  CSAT-CMHS  demonstration 
dollars. 
Clients:  The  108 clients  have  severe  mental  illnesses.  Average  age is the  early  30s. 
Some  reportedly  have  borderline  personalities,  especially  fem~les~  Many  use  ~lcohol 
to self-medicate;  they  also use  cocaine,  PCP,  and  crack.  Many  clients  have  been 
homeless.  All receive  SS1 and  Medicaid. 
Services:  Intensive  case  management  is the  agencys core  service.  Other  program 
components  include  medication  management,  groups  that  address  daily living skills, 
mental  health  and  substance  abuse  education,  and  a Double  Trouble  12-step  group. 
Ten Day  lkeatmentlPamal  Hospitaluation  Bograms 
Dav Treatment/Partial  Hospitalization  Promam  #1 
Structure:  Run  by a CMHC  in Ohio,  this program  was established  in  1988.  It 
operates  5 days a week,  4 or 5 hours  a day.  It was established  when  the  county 
mental  health  board  identified  a need  for services  for people  with severe  mental 
illness  and  substance  abuse  problems.  Most  clients  remain  in the  program  for 6 to 9 
months,  although  they  may stay indefinitely.  Staff include  a psychiatrist,  case 
managers  with caseloads  of 15, counselors,  a nurse,  and  an art  therapist. 
Funding  The  county  mental  health  board  is the  primary  funder.  The  program  bills 
Medicaid  and  Medicare  for some  services  as a partial  hospitalization  program.  United 
Way also provides  some  funding, 
13
 Clients:  The  program  has some  50 active  clients,  predominantly  African  American 
men  with  schizophrenia/schizo-affective  disorders.  The  average  age  is 32.  Clients  are 
polyusers.  The  most  popular  drugs  are  crack  cocaine  (58 percent),  alcohol  (35 
percent),  and  marijuana  (4 percent).  In addition,  50 percent  of clients  may be  on 
parole  at any one  time. 
Services:  Services  include  intensive  case  management  with  referral  to  services  as 
needed,  medication  management,  group  and  individual  counseling,  education, 
recreation  therapy  to  counter  boredom  and  teach  clients  socialization  skills,  and  12-
step  groups,  both  traditional  and  modified.  Case  managers  sometimes  accompany 
clients  to  12-step  groups  in  the  community  to  help  them  feel  more  comfortable  with 
participating. 
Dav Treatment/Partial  Hospitalization  Promam  #2 
Structure:  This  program  in Texas  is only a few months  old.  It is run  by the  county 
comprehensive  CMHC  and  operates  5 days a week  from  8 am.  to 5 pm.  It is 90 days 
in duration,  with some  flexibility for a client  to extend.  The  agency  runs  a residential 
program  for clients  with co-occurring  MH/SA  disorders  which  led to the  formation  of 
this day program.  Staff include  a director  who also serves  as a caseworker  and 
counselor,  a psychiatrist,  and  a licensed  vocational  nurse. 
Funding  The  program  receives  county  mental  health  dollars  and  Medicaid 
reimbursement. 
Clients:  The  program  serves  20 severely  mentally  ill clients,  60 percent  of them  male 
and  most  in their  20s and  30s.  Some  30 percent  receive  SS1 and  Medicaid.  About  25 
percent  are  referred  to the  program  on probation.  Many  have  histories  of physical  or 
sexual  abuse  (reportedly  up  to 90 percent  of females  and  50 percent  of males),  or 
come  from  families  where  substance  abuse  is present. 
Services:  The  agency  provides  a continuum  of services  from  outreach  to treatment  to 
aftercare,  allowing  clients  to move  back  and  forth  between  programs  as needed.  This 
program  focuses  on education  and  peer  support,  mostly within  groups,  to encourage 
sobriety  and  increase  client  stability.  It provides  medication  management,  education, 
12-step  groups  in the  community,  and  modified  12-step  discussion  groups  in house. 
Dav Treatment/Partial  Hospitalization  Program  #3 
Structure:  This  6-year-old  program  is in upstate  New York.  According  to the 
director,  the  program  is approaching  maturity.  It is run  by the  mental  health 
department  of a hospital  and  operates  5 days a week  for 5 hours.  Clients  stay an 
average  of 18 to 36 months.  Staff include  primary  care  counselors,  who  oversee 
treatment,  a vocational  rehabilitation  counselor,  and  a recreation  counselor, 
14
 Funding  Though  begun  initially with Federal  grant  monies,  the  program  now is 
funded  primarily  through  Medicaid  reimbursement. 
Clients:  The  programs  mission  is to seine  persons  with severe  mental  illnesses  who 
have  failed  in other  treatment  programs.  Their  clients  include  persons  with  anxiety 
and  personality  disorders  in addition  to schizophrenia  and  depression.  Sixty percent  of 
the  50 clients  are  male,  most  in their  mid-20s  to mid-30s.  Twenty  percent  are  African 
American.  Almost  all clients  receive  SS1 and  Medicaid.  Many  clients  have  been  or 
are  at risk of being  homeless,  and  20 to 30 percent  are  on parole.  Reportedly,  clients 
are  at  all levels  of functioning. 
Services:  The  program  provides  medication  monitoring,  individual  therapy,  vocational 
counseling,  group  counseling  and  education.  Clients  attend  the  groups  most  in 
keeping  with their  individual  needs;  some  20-25 groups  are  offered  every  4 month 
cycle.  Some  clients  also  attend  12-step  meetings  in the  community.  Through  case 
management,  access  to other  services  is provided. 
Dav Treatment/Partial  Hos~italization  Pro~ram  #4 
Structure:  This  4-year-old  program  in Indiana  was established  by a CMHC.  It is 
housed  in the  same  building  as a homeless  shelter.  The  program  operates  Monday 
through  Friday,  6 hours  a day.  Up  to 40 treatment  days per  client  are  covered  under 
State  Medicaid  guidelines.  The  program  is staffed  by a director  and  two counselors. 
Funding  Half  of the  funding  is from  the  State  substance  abuse  agency  and  half from 
Medicaid  or Medicare. 
Clients:  The  program  serves  both  clients  with co-occurring  MH/SA  disorders  and 
others  with problems  only with substance  abuse.  Clients  average  between  30 and  40 
years  old.  Twenty  percent  are  homeless  persons  living at the  shelter;  other  clients 
include  court-order  indigents  and  clients  referred  by the  CMHC.  Between  80 to 90 
percent  of the  clients  are  male;  another  program  in the  city serves  women.  Besides 
having  a wide variety  of problems  related  to mental  illness  or substance  abuse,  clients 
are  also very mixed  in terms  of levels  of functioning. 
Sexvices:  This is a group-oriented,  12-step-based  program  (specifically  focused  on 
steps  1-3.)  Attendance  at sessions  is mandatory.  Groups  include  12-step  study 
sessions,  education,  daily Alcoholics  Anonymous  meetings,  group  therapy,  and 
community  meetings.  Medication  needs  are  met  by the  CMHC. 
Dav Treatment/Partial  Hospitalization  ProEram  #5 
Structure:  This  4-year-old  program  is located  in a suburb  of a major  metropolitan 
area  in the  South,  It operates  Monday  through  Friday,  6 hours  a day.  There  is a 90 
day time  limit,  recently  imposed  due  to a flood  of new clients  (see  Clients  below). 
15
 FundirIg  Funding  is primarily  Medicaid  reimbursement,  but  also includes  some

private  reimbursement.  However,  the  Director  reported  that  the  county  is now

evaluating  day treatment  programs  in view of the  potential  privatization  of government

services.  It is not  clear  how future  changes  will affect  the  program.

Clients:  About  30 clients  attend  the  program  on a given day.  They  are  primarily

males  between  20 and  40 years  old.  Seventy-five  percent  are  African  American.  The

majority  are  on SS1 and  Medicaid.  Many  have  been  homeless  or are  highly transient.

They  have  severe  mental  illnesses  and  most,  according  to the  director,  also have  a

personality  disorder.  Some  are  mentally  retarded  or brain-injured.

Right  now the  program  is flooded  with clients  unable  to enter  the  State  hospital  in the

area,  which  closed  to voluntary  admissions.  Clients  are  being  referred  by hospitals  and

mobile  crisis units,  often  without  any background  paperwork,  including  a diagnosis  or

record  of medications.  This  is creating  considerable  chaos  in the  program,  including  a

very high turnover  rate.

Sewices:  The  program  is primarily  group-oriented,  with a strong  12-step  format  and

emphasis  on education.  Clients  must  be  stable  on medications,  show some  ability  to

learn,  and  make  some  visible  effort  to adhere  to the  programs  schedule  and  demands.

Services  include  medication  management  in connection  with neighboring  CMHCS,  12-

step  and  12-step  study groups,  education,  and  a strong  socialization  and  recreational

component  to involve  clients  in sober  activities.  Staff include  the  director,  a nurse,  a

substance  abuse  counselor,  and  a human  service  technician.  Each  person  handles  a

caseload,  runs  groups,  and  participates  in all other  program  activities.

Dav Treatment/Partial  Hospitalization  Pro~ram  #6

Structure:  This  l-year-old  program  is run  by a private  non-profit  agency  in South

Carolina  in the  foothills  of the  Blue  Ridge  Mountains.  It is one  of four  programs

serving  persons  who are  both  homeless  persons  and  have  a mental  illness;  the  other

programs  are  outreach,  housing,  and  an HIV  program.  Clients  are  housed  by the

agency, which  serves  as representative  payee  for those  on SS1; they  then  may access

this program  and  other  semices  as needed.  Clients  may remain  in the  program  for up

to 2 years,  then  enter  Section  8 housing  and  continue  in the  agencys case

management  program.

Funding  Funding  is primarily  Medicaid  reimbursement,  with some  private

contributions.  The  agencys housing  program  receives  funding  from  HUD;  the

outreach  program  is funded  by a Federal  McKinney  Act grant  (for  services  to the

homeless).

Ci.ients:  The  program  serves  16 persons,  half  males,  half females,  with  an average  age

of 35.  Half  are  minorities.  Clients  have  severe  mental  illnesses.  The  majority  receive

SS1, Medicaid,  or both;  some  receive  veterans  benefits.  Besides  being  homeless,  a

16
 third  have  a prison  record,  a third  are  developmentally  disabled,  and  many  were  raised 
in dysfunctional  families,  or in a foster  home  or institution. 
Services:  Services  include  case  management,  medication  management,  counseling, 
education,  a special  Alcoholics  Anonymous  for homeless  people  (clients  also go to 
community  AA meetings),  and  recreational  activities,  including  1 week  a year  spent  at 
a church  camp  rented  by the  agency.  Recreational  activities  include  ballroom  dancing, 
a talent  show, and  a Hopes  Course  designed  to build  self esteem.  A strong  emphasis 
on permanency,  a foreign  concept  to most  homeless  people,  underlies  the  program. 
The  program  has  25 rules  which  the  clients  vote  on and  then  police  themselves;  the 
director  believes  that  structure,  with consequences  for violating  rules,  is important. 
Dav Treatment/Partial  Hospitalization  Program  #7 
Structure:  This  2-year-old  day  treatment  program  in Oregon  is run  by  a mental  health 
provider.  The  program  is part  of a comprehensive  array  of services  offered  by the

agency.  Clients  may stay in the  program  indefinitely.  Staff  include  an administrator,

two case  managers,  two specialists  on co-occurring  MH/SA  disorders  who  run  groups,

and  a half  time  occupational  therapist.

Funding  This  is one  of the  CSAT-CMHS  demonstration  sites.  In addition  the  agency

receives  Medicaid  and  Medicare  reimbursement,  and  private  donations.  Reportedly,

the  program  has  not  been  able  to access  State  substance  abuse  dollars.

Clients:  The  approximately  140 clients  are  homeless  or at risk for hopelessness.

They  are  90 percent  male  and  range  in age from  19 to 55.  Most  have  schizophrenia,

and  20 percent  suffer  from  depression.  From  50 to 75 percent  receive  SS1, Medicaid,

or both.

Services:  Since  the  program  serves  homeless  people,  the  first  task  of the  case

managers  is to  find  housing  (one  group  home  is specifically  for  persons  with  co

occurring  MH/SA  disorders),  as well  as link  the  client  to  a psychiatrist,  nurse,  and

medications.  Some  clients  receive  acupuncture  to  deal  with  cravings  due  to  addiction.

The  in-house  program  reportedly  takes  a biopsychosocial  approach,  offering  education,

group  treatment,  and  step  study  or  modified  12-step  groups  (the  first  three  steps  only).

Art  and  music  therapy,  and  recreational  activities,  are  also  part  of  the  program.  Staff

are  trying  different  approaches  in  an  effort  to  meet  client  needs.

Dav Treatment/Partial  Hospitalization  Prom-am  #8 
Structure:  This  agency  is located  in a medium  sized  city in Ohio.  In addition  to this 
6-year-old  partial  hospitalization  program,  the  agency  also runs  a small  residential 
program  and  an outpatient  program.  Partial  hospitalization  is highly structured  and 
runs  5 days a week,  3 hours  a day.  Treatment  is conducted  in 12 week  modules, 
although  clients  time  in treatment  is not  limited. 
17
 Funding  Theprogram  is funded  through  coun~tw  dollars,  State  mental  health

dollars  (through  thecounty),  andsome  Federal  grants.  Theprograms  funding  is tied

to a State  initiative  to reduce  hospital  stays; thus  its objective  is to keep  clients  out  of

the  hospital.  The  agency  designated  mental  illness  as the  primary  disorder  due  to

county  requirements,  and  Medicaid  requirements  dictate  a client-staff  ratio  of 1 to 6.

Clients:  The  program  serves  45 clients,  50 percent  of whom  are  minority.  Average

age is 35 years  old, and  the  program  has few clients  over  45.  Clients  levels  of

functioning  vary.  Many  can take  care  of themselves  but  have  low socialization  skills

and  few friends.  Some  are  in the  program  due  to a court  order.

Semites:  The  agency  has  recently  intensified  its program  by moving  from  a social  to a

therapeutic  approach,  and  this particular  program  is now undergoing  an evaluation.

Clients  participate  in individual  treatment  and  group  sessions.  Groups  are  based

loosely  on the  12-step  model  and  range  from  education  on mental  illness  and

substance  abuse  to daily living skills to alternatives  to substance  abuse.  The  program

also provides  case  management,  vocational  education,  recreation,  and  some  housing.

Dav Treatment/Partial  Hospitalization  Pro~ram  #9

Structure:  This  8-month-old  intensive  outpatient  program  in Miami,  Florida  is run by

a mental  health  center  with a Hispanic  clientele.  It operates  Monday  through  Friday

from  10 am  to 3 pm.  Clients  are  expected  to take  about  9 months  to pass  through  the

programs  3 levels,  although  deadlines  are  flexible.  Staff include  a psychiatrist,  a case

manager,  two clinicians,  a family therapist,  and  a person  who  runs  stress  management

groups.

Funding:  The  program  is funded  by CSAT-CMHS  demonstration  funds.

Clients:  The  program  is designed  for Hispanic  persons  who  are  both  homeless  and

have  co-occurring  MH/SA  disorders.  The  12 clients  (10 of them  male)  are  Cuban  or

Cuban-American  and  speak  Spanish.  They  average  around  35 years  old.  All have

severe  mental  illnesses  (paranoid  schizophrenia,  schizo-affective  disorders)  and  use

crack;  cocaine,  or alcohol.  From  70 to 80 percent  receive  SS1 and  Medicaid.

The  program  is growing.  At the  time  they were  contacted,  they  expected  to serve  40

clients  by the  end  of 1994.

Services:  The  program  takes  an educational,  behavioral  approach  in a Hispanic

environment  which  respondents  described  as friendly and  emotional.  There  are

three  levels.  The  first concentrates  on psychiatric  stabilization,  the  second,  on coping

with mental  illness,  and  the  third,  on required  attendance  at two psychotherapy  groups

a day.  Services  include  case  management;  group,  individual,  family,  and  recreational

therapy;  and  assistance  with stress  management.  Clients  also are  encouraged  to attend

12-step  groups.  After  graduation,  clients  continue  in aftercare.

18
 Dav Treatment/Partial  Hospitalization  Promam  #10 
Structure:  This not-for-profit  multi-service  agency  in New York  City was founded  25 
years  ago to help  homeless  substance  abusers  and  has since  added  mental  health  care 
to its services.  The  program  for clients  with co-occurring  MH/SA  disorders  was 
established  in  1986.  The  agency  offers  a continuum  of care  that  includes  housing 
programs  and  a day treatment  program  for people  with co-occurring  MH/SA 
disorders.  Clients  can  take  advantage  of both  programs  at once  and  stay with the 
agency  indefinitely.  (See  also Residential  Programs) 
The  day treatment  program  runs Monday  through  Friday,  9:00 am  to 2:30 pm.  It 
emphasizes  activity  and  participation,  and  case  managers  ensure  that  program 
attendance  is high.  A multi-disciplinary  team  of primary  therapists,  case  managers,  a 
part-time  psychiatrist,  and  part-time  art  and  music  therapists,  provides  care.  Client 
input  on program  is encouraged  through  one-on-one  meetings  between  elected 
consumer  representatives  and  the  program  director. 
Funding  The  program  receives  funds  from  the  CSAT-CMHS  demonstration  program, 
and  Medicaid  and  Medicare  reimbursement. 
Clients  The  program  serves  36 clients  at a time,  with a total  of 50 a year.  Currently, 
85 percent  of the  clients  are  male,  80 percent  are  minority,  and  average  age is 
between  30 and  40 years  old.  All receive  SS1 or SSDI  or VA benefits  as well as 
Medicaid.  In addition  to severe  mental  illnesses,  some  clients  are  infected  with the 
HIV/AIDS  virus,  many  have  experienced  physical  abuse,  been  homeless,  or served 
time  in jail. 
Sewkxs  Services  include  medication  management,  individual  therapy,  group  therapy, 
modified  12-step  groups  which  meet  in house,  education,  music  and  art  therapy,  field 
trips,  and  physical  exercise.  Art  therapy  is said to have  been  especially  successful. 
Average  daily attendance  is reportedly  over  90 percent. 
Five Continuous  Treatment  Team Programs 
Continuous  Treatment  Team  Prom-am  #1 
Structure:  This is a pilot  demonstration  program  begun  in 1990 which  is part  of a 
previously  existing  program  for persons  with severe  mental  illnesses  only.  Located  in 
Wisconsin,  the  program  constitutes  an outpatient  department  of the  State  mental 
hospital  located  there.  Based  on a medical  model,  the  program  uses a continuous 
treatment  team  with staff from  many  disciplines,  supervised  by psychiatrists.  The 
programs  goal is to offer whatever  assistance  is needed  by individual  clients  to 
improve  their  functioning  in the  larger  community.  Clients  are  expected  to remain 
with  the  program  for life. 
19
 Funding  State  hospital  funding,  private  insurance,  and  Medicaid  are  sources  of 
funding.  The  State  has  a special  Medicaid  reimbursement  category  called  community 
support  services which  allows billing for services  related  to both  mental  health  and 
substance  abuse. 
Clients:  The  75 clients  with co-occurring  MH/SA  disorders  constitute  about  60 
percent  of all clients  in this program  (the  others  have  mental  illnesses  only).  They  are 
90 percent  male.  To  enter  the  program,  clients  must  have  spent  less than  a 1 year  in 
the  State  hospital,  be between  18 and  30 years  old, and  have  a chronic  mental  illness 
(Axis I disorder).  Drugs  used  and  abused  include  alcohol,  marijuana,  cocaine,  and 
over-the-counter  stimulants. 
One  third  of the  clients  are  described  by the  director  as moving targets  whose 
substance  abuse  pre-dated  their  mental  illness  and  is very entrenched.  They  have 
failed  in every  other  treatment  program  and  are  very difficult  to engage. 
Services:  The  program  takes  a highly individualized  approach  to clients.  It has  a 
strong  emphasis  on setting  limits  and  also relies  heavily  on work  as a treatment 
modality,  finding  that  many  clients  use substances  just  to counteract  boredom  and 
have  something  to do; the  program  has a 50 to 60 percent  job  placement  rate.  The 
program  also serves  as representative  payee  for its clients. 
Several  members  of the  team  work with each  client  simultaneously  and 
interchangeably,  giving clients  several  people  to rely on and  allowing  staff  to share 
responsibility  for clients.  Staff  also work with important  people  in their  clients lives. 
Continuous  Treatment  Team  #2 
Structure:  This  program,  located  in a rural  two-county  area  in Wisconsin,  is run  by a 
mental  health  provider.  It takes  a long-term  view of treatment,  expecting  to carry 
clients  for the  rest  of their  lives.  Staff  consists  of a psychiatrist,  a clinical  coordinator, 
and  case  managers  with  14 clients  each,  who serve  clients  in the  home  as well as 
referring  them  to services  outside. 
Funding  The  program  receives  Medicaid  reimbursement  under  a special  State-
established  category  called  community  support  services, which  allows billing for 
services  related  to both  mental  health  and  substance  abuse. 
Clients:  Two-thirds  of the  programs  51 clients  are  male.  They  range  in age from  22 
to 53.  In addition  to major  Axis I mental  illnesses  (a program  requirement),  many 
clients,  especially  younger  ones,  reportedly  have  post  traumatic  stress  disorder  due  to 
severe  childhood  abuse.  They  are  using or abusing  alcohol,  marijuana,  and  over-the-
counter  and  prescription  medications.  Almost  all clients  are  on some  form  of public 
assistance. 
20
 Services:  Theagency  integrated  substance  abuse  treatment  into  its mental  health 
treatment,  realizing  that  most  clients  were  going to need  long-term  substance  abuse 
treatment  combined  with a great  deal  of support  and  interventions  in many  arenas. 
The  program  tries  to provide  clients  with structure  and  looks  for replacement 
behaviors  for substance  abuse. 
Services  include  case  management,  medication  management,  psychiatric  treatment, 
psychosocial  rehabilitation,  and  vocational  support  (finding jobs  and  supporting  those 
who work  - about  25 percent  of their  clients).  Some  clients  receive  help  in the  home 
with  things  such  as money  management,  hygiene,  or buying  and  preparing  food, 
through  ancillary  services  purchased  from  another  program.  Respondents  described 
the  programs  approach  as being  individualized  and  whole health,  meaning  that  they 
try to meet  many  different  client  needs. 
Continuous  Treatment  Team  #3 
Structure  This  continuous  treatment  team  is one  of two programs  (the  other  is a 
residential  program)  specifically  for persons  with co-occurring  MH/SA  disorders. 
Teams  of case  managers,  nurses,  clinicians,  associate  and  assistant  clinicians  work with 
clients  to provide  whatever  services  they need.  Clients  may graduate  from  the 
residential  program  to this program,  where  they may stay indefinitely. 
Funding  The  agency  is in the  second  year  of a 3 year  Federal  grant  from  the  Center 
for Substance  Abuse  Treatment  to serve  persons  of color,  pregnant  women,  and 
people  with HIV.  A recent  cut in the  grant  reportedly  led  the  agency  to eliminate  its 
program  evaluation  effort. 
Clients:  The  program  serves  about  70 clients,  80 percent  of them  male,  They  have 
schizophrenia  or major  depression,  and  some  have  personality  disorders.  They  most 
commonly  abuse  alcohol  or crack  cocaine;  use of heroin  is reportedly  on the  rise and 
polyabuse  is also  common.  Many  clients  are  HIV  positive,  and  all are  people  of color. 
Histories  of hopelessness  or brushes  with the  criminal  justice  system  are  common. 
Almost  all clients  receive  SS1, Medicaid,  or both. 
Services:  The  goal of staff is to help  clients  lead  as normal  a life as possible  by 
providing  whatever  help  they need,  from  the  most  basic  life skills to education, 
vocational  education,  and jobs.  The  agency  provides  medication  management, 
counseling,  education,  12-step  groups  (including  a Double  Trouble  group),  and  a 
social skills (recreation)  group  described  by staff as very therapeutic.  Clients  are 
referred  out  to other  agencies  for services  not  provided  by this program. 
Continuous  Treatment  Team  #4 
Structure:  This  program  operates  community  treatment  teams  of 5 to 7 staff, 
including  supervisors,  case  managers,  and  specialists  (vocational,  rehabilitation, 
substance  abuse).  Located  in Missouri,  the  program  was started  2 years  ago when  its 
21  parent  mental  health  center  found  that  referring  their  homeless  clients  with co

occurring  MH/SA  disorders  to traditional  substance  abuse  treatment  was not working  -

clients  resisted  going  and  continued  using.

Funding  The  program  receives  CSAT-CMHS  demonstration  funds.  The  parent

agency  also receives  ACCESS  funds  for services  to homeless  persons  with mental

illnesses.

Clients:  The  program  serves  some  65 clients,  half  male  and  half female,  with an

average  age in the  early  30s.  Reportedly,  the  number  of African  American  male

clients  is growing.  Clients  have  schizophrenia  or depression,  and  some  have

personality  disorders.  They  use or abuse  alcohol,  marijuana,  and  crack  cocaine;  heroin

use is reportedly  rising.  Many  clients  have  a history  of hopelessness  and/or

unsuccessful  treatment,  and  lack social  support.  Some  have jail  or prison  records.

The  majority  receive  SS1, Medicaid,  or both.

Semites:  Teams  reportedly  take  a generalist  approach  in providing  supportive

counseling,  skill building,  and  referral  to needed  semices  both  in and  outside  the

parent  agency.  Services  are  described  as continuous  (for  an unlimited  time  period),

holistic  in addressing  a variety  of client  needs,  and  individualized  to match  the  need  of

each  client.

Continuous  Treatment  Team  #5

Structure:  This  new program  is located  in a 3-county,  670 square  mile  rural/suburban

area  of Virginia.  It was developed  by a former  substance  abuse  clinician  who noticed

that  clients  with  co-occurring  MH/SA  disorders  were  falling  through  the  cracks  of the

existing  service  system.  She supervises  teams  of dual diagnosis  specialists,  case

managers,  and  clinicians.

Funding  The  parent  agency  is a county  mental  health/mental  retardation  agency.  We

do not  know whether  this particular  program  receives  any special  funding  from  any

source.

Clients:  Eighty  percent  of the  75 clients  are  male,  with an average  age  of 37.  In

addition  to severe  mental  illnesses,  up to half  of the  clients  have  personality  disorders.

The  majority  receive  SS1 or SSDI.

Senkes:  According  to the  founder,  this program  is based  on a model  developed  by

Dartmouth  University  to provide  integrative,  comprehensive,  concurrent,  sequential

services  through  a continuous  treatment  team.  The  program  provides  outreach,

psychiatric  care  and  other  clinical  services,  intensive  case  management  (including

advocacy),  club house,  residential  services,  and  education.  Also,  65 clients  are  in a

special  pre-treatment  group;  10 are  in a relapse  prevention  group.

22
 One Other Program 
Structure:  Wespoke  totheday  manager  inasingle  room  occupancy  hotel  (SRO)  ina 
Vermont.  Theposition  wasestablished  2yearsago  following  arashof  false  fire 
alarms,  and  subsequent  warnings  by the  city to the  entity  running  the  SRO.  The 
manager  works  6 hours  a day, 5 days a week. 
Funding  The  SRO  receives  funding  from  HUD  (moderate  rehabilitation)  and  the 
State,  and will soon  receive  HUD  Shelter  Plus Care  dollars.  The  managers  position  is 
funded  by the  local  CMHC. 
Clients:  At least  half  of the  SROS 25 residents  have  co-occurring  MH/SA  disorders. 
The  majority  are  men,  about  40 years  old, who have  serious  mental  illnesses,  drink 
mainly  beer,  are  very isolated  socially, and  have  lived at the  SRO  for years.  They  are 
clients  of the  CMHC.  A smaller  number  of residents  are  young  men,  referred  by the 
State  hospital  or a local  homeless  program,  who are  heavy  drinkers.  Reportedly 
resistent  to treatment,  they  tend  to have  a social  support  network  of some  kind  still 
intact,  and  almost  always leave  the  SRO  within  a few weeks  or months. 
Sexvices:  No treatment-related  services  are  offered  in the  SRO.  Residents  who  are 
severely  mentally  ill are  clients  of the  CMHC  and  receive  case  management  and  other 
services  there.  The  manager  views her  main  goal  as trying to overcome  clients 
isolation  through  an open  door  policy, trying to make  a personal  connection  and 
draw  residents  into  contact  with her  and with each  other.  However  she is very 
disappointed  by the  lack  of in-house  services  and  activities,  from  treatment  to 
recreation  and  socialization,  which  she believes  residents  desperately  need. 
23