Department of Health and Human 
SelVices 
OFFICE OF 
INSPECTOR GENERAL 
SERVICES TO PERSONS WITH 
CO-OCCURRING MENTAL HEALTH 
AND SUBSTANCE ABUSE DISORDERS 
PROVIDER PERSPECTIVES 
n\7l('es. 
JU 
Jit 
GffBS BROWN 
Inspector General 
JU 
1995 
:J.cf)d'za 
OEI-05-94-00150  OFFICE OF INSPECTOR GENERA 
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 Servces
' (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 
Offce of Audit Services, the
Offce of Investigations, and the Offce of Evaluation and Inspections. The OIG also 
. correct them.  informs
the Secretary of HHS of program and management problems and recommends courses to
SERVICE 
OFFICE OF  AUDIT 
The OIG's Offce of Audit Servces (OAS) provides all auditing servces 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 
carryng 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 INTIGATIONS 
The OIG'
s Offce 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. 
AN 
OFFICE OF EVALUATION  INSPECTONS 
The OIG's Offce 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 effciency, vulnerabilty, 
and effectivenes of departmental programs. 
This report was prepared under the direction of Wiliam Moran
, the Regional Inspector 
General for the Offce 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 at 312/353-
4124.  Department of Health and Human 
SelVices 
OFFICE OF 
INSPECTOR GENERAL 
SERVICES TO PERSONS WITH 
CO-OCCURRING MENTAL HEALTH 
AND SUBSTANCE ABUSE DISORDERS 
PROVIDER PERSPECTIVES 
snvrC'l'J'. 
JU 
GffBS BROWN 
Inspector General 
JU 
-1  1995 
rtla  OEI-05-94-00150  EXECUTIVE  SUMMARY

PUROSE 
Describe the experiences of staff that work directly with people who have co-occurring 
mental health and substance abuse disorders. 
BACKGROUN 
The National Comorbidity Survey, a large general population survey conducted from 
1990 to 1992, estimates that in a given year, from 7. 6 to 9.9 milion Americans suffer 
from co-occurring mental health and substance abuse  (MH/SA)  disorders. Estimates 
of co occurrence in non-surveyed populations (institutionalized or homeless persons 
youth, and adults 55 and over) brings the total to 8.3 to 10.8 milion individuals. 
This population is heterogeneous in terms of types of mental disorders, levels of 
involvement with alcohol and other drugs, and degree of functioning. Few receive 
integrated treatment in a single setting, yet without it, response to treatment is likely 
to be poor. Information on effective treatment modalities is stil emerging and co
disorders are not addressed in most higher education or on-
occurring  MH/SA  the-job 
training curricula. 
The Public Health Service (PHS) funds a number of servces and activities relevant to 
this population, especially in the Substance Abuse and Mental Health Servces 
Administration (SAMHSA), where their national advisory council established a work 
group on services integration which is currently focusing on this issue. Two programs 
are targeted at this population (Projects for Assistance in Transition from 
Homelessness and a special demonstration program). Clinical education, training, and
technical assistance activities or programs are also funded by SAMHSA. The National 
Institutes of Health, Health Resources and Services Administration, Indian Health 
Servce, Health Care Financing Administration, and Social Security Administration 
fund servces that could serve this population. The extent to which any of these 
prognims actually reach people with co-occurring MH/SA disorders is unknown. 
This report conveys the experiences and perspectives of 71 people working in 30 
community-based programs, located in 20 States, that treat people with co-occurring 
MH/SA disorders. Discussions with SAMHSA revealed that information on front-line 
workers was of interest and would complement the programmatic information coming 
from the special demonstration program mentioned above. Later in the study, 
SAMHSA staff expressed interest in knowing about the programs in which these 
respondents work. Hence we have produced a companion report (OEI-
05-94-00151) 
with that information.
 ,,  ""
 
The combination of this survey analysis and the program descriptions provides as 
complete a picture as possible about issues, successes, and problems in the emerging 
field of treating this population. 
FININGS
Most front-line staff work in new programs and have little education, training, or prior 
exerience specifcally related to co-occurrng mental health and substance abuse 
disorders. 
The majority of the programs in our sample are 3 years old or less, and 60 percent of 
the front-line staff have worked with this population for 3 years or less. Most front-
liners work in teams, and are responsible for case management, counseling, or 
education. They lack formal education and training specifically on co-occurring 
MH/SA disorders. Many feel overburdened by the demands of the job and see 
burnout as a real threat. 
The fit challenge that front-line staff face in their working environment is that their 
clients have a host of serious problems in addition to mental illness and substance abuse. 
Front-line staff report that many of their clients have severe, long-standing ilnesses. 
Other common characteristics of their clients that they report include histories of 
homelessness, contact with the criminal justice system, and dysfunctional family 
backgrounds. Many clients are described as resistant to treatment. 
Front-line staff have many goals for clients, with a long-term view of recovery. 
Respondents named several goals they have for clients, such as long-term sobriety and 
increased self-sufficiency. They also emphasize that for most clients  recovery" js a 
relative term and wil take years to achieve. When asked to name the most important 
personal attributes needed to be effective , they most frequently said  patience. 
Front-line staff describe their approaches to clients as holistic, individualized, flexle
, or 
creatie. They say that establishing trt with clients is ke, but very difcult to do. 
The majority of staff say they are trying to address many client needs besides those 
related to mental ilness and substance abuse, primarily through case management. 
They are tryng to be flexible and creative in adapting their approach to meet the 
individual needs of clients. They say that building trust and a personal relationship 
with clients is key to making progress but very difficult to do. 
Front-line staff defne success for most clients as making incremental progress over time.
Given the severe, longstanding problems of clients, staff view treatment for most as an 
ongoing, lengthy process. They take satisfaction from seeing small steps toward 
recovery such as improved compliance with medications or reduced substance use.  RECOMMNDATION 
The Public Health Service should develop a plan to increase knowledge about co
occurg 
mental health and substance abuse disorders and their treatment among 
clinicians, other professionals
, and service providers. 
Front-line staff working with this population face tremendous challenges. Their clients 
are often seriously il and highly dysfunctional, and staff lack the education, training, 
and experience needed to work effectively with them. Furthermore, the number of 
such clients is reportedly growing nationwide. 
We recommend that PHS develop a plan to use its arsenal of education, training, and 
technical assistance resources more strategically on behalf of clinicians, other 
professionals, and the programs they work in. In this effort, we suggest that PHS 
collaborate with other Federal agencies with relevant services, including the Social 
Security Administration and the Departments of Veterans Affairs, Housing and Urban 
Development, and Justice. We also suggest that they consult with grantees, national 
associations, professional organizations, experts, researchers, clinicians, and other 
practitioners. Finally, we suggest that existing technology be used as much as possible 
to produce and disseminate curricula and educational materials at a reasonable cost. 
AGENCY COMMNT 
The Public Health Service concurred with our recommendation. Their comments are 
attached as Appendix A. They also submitted a number of technical 
comments on 
which we have based some revisions to the text. 
iii    .. . . . . . . . . . . . . . . . . . . . . . ..  .. .  ..  ..  ..  ...   ...   ...  . .  ...   ...   ...  ..   ...   ...  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  ..  . . . ...   ...   ..  ..  ..  ..  ..  ..  ..  ..  ..  ....  
TABLE OF CONTENTS
PAGE
SUMY
EXECUIV 
INODUCTON. . 
. . . . . . . . . . .. 1
FININGS. . 
. . . . . . . . . . . . . . . . . 5
. Background and experience of front-line staff. . . . . . . . . . . . . . . . . . . . . . . . . . 5
ts ..... . 
. Characteristics of their clien  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
. Their goals for clients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
. Their approaches to serving clients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... 10
. Their views of success. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 
RECOMMNDATION. . . . . . . . . 
APPENDIX A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . A- , .
INTRODUCTION

PUROSE 
Describe the experiences of staff that work directly with clients with co-occurring 
mental health and substance abuse disorders. 
BACKGROUN 
The National Comorbidity Survey, a large general population survey conducted from 
1990 to 1992, found that 53 percent of respondents with alcohol abuse or dependence 
over their lifetime also had a mental disorder over their lifetime
, while 36 percent had
a lietime ilicit drug use disorder. Fifty-nine percent of the respondents with a history 
of ilicit drug abuse or dependence over their lifetime also had a mental disorder over 
, and 71 percent had a alcohol use disorder over their lifetime. In any 
their lifetime
given year, Survey data reflect that an estimated 7.  9 milion persons suffer from
6 to 9.
co-occurring mental health and substance abuse (MH/SA) disorders. 
The literature strongly emphasizes the heterogeneity of this population in terms of 
, levels of involvement with alcohol and other drugs
tyes of mental disorders , 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 jf treated for only
one disorder, response to treatment is likely to be poor. 
Information on effective treatment modalities is stil emerging and few studies 
document effective service delivery, treatment approaches
, and outcomes. Also, co
occurring MH/SA disorders are not addressed in most higher education or on-
the-job 
training curricula.
The broad social consequences of failing to adequately treat this population include 
homelessness, 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. 
Programs and Activities for Persons with Co-Occurg MH/SA Disorders 
In the Department of Health and Human 
Services (HHS), the Public Health Service 
funds many services and activities relevant to this population. 
1 Since NCS data reflect only the household population 
ages  15- a tre picture of the magnitude of this problem
must reflect an additional. l milion insritutional population  million homeless  05 millon youth age  ()14 and.4 to 
6 millon adults age  55  or over, for a lolal estimated  to 10.8 millon individuals.  Substance Abuse and Mental Health 
The  SelVices Administration  has many
(SAMHSA) 
programs that are directly or indirectly targeted to serve people with co-occurring 
MH/SA disorders. The national advisory council of SAMHSA has a working group on
servces integration which is currently focusing on this issue. A SAMHSA work group
has also 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 Homelessness (PATH) is 
a formula grant program to States and territories with a specific 
legislative mandate to 
serve this population. Funded at $29 milion in Fiscal Year (FY) 1994
, PATH 
provides mental health and other services to homeless 
individuals and at-risk 
populations that are severely mental1y ill or have co-occurring MH/SA disorders. 
Secondly, a demonstration program for homeless individuals with such 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 milion to develop and test models of effective assessment and 
intervention for this population. In FY 1994, several providers wil 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
milion for FY 1994) and the substance abuse prevention and treatment 
block grant
($1.1 bilion in FY 1994). Nine Access to Community Care and Effective 
Services and
Support demonstration grants ($19.4 milion) are testing services integration
approaches for persons with severe mental ilnesses and/or substance abuse and the
Community Support Program has funded demonstration projects. SAMHSA also 
funds various clinical education, training, and technical assistance activities or
programs.
Elsewhere in HHS fund research and services
, the  National Institutes of Health 
demonstrations through the National Institutes of Mental Health
, Drug Abuse, and
Alcohol Abuse and Alcoholism. The  Health Resources and SelVices Administration
funds the Health Care for the Homeless Program and Ryan White 
programs for
funds services for American
persons with HIV/AIDS. The  Indian Health SelVice 
Indians and Alaska Natives. The  Health Care Financing Administration  funds
Medicare and Medicaid for health care and related 
services. The  Social Security
funds the Social Security Disability Income and Supplemental Security
Administration 
Income programs.
Outside HHS Department of Housing and 
, the  Department of Veterans Affairs  and the 
(HUD) both deal with this population in their homeless as well as
Urban Development 
deals with this population via the courts 
other programs. The  Department of Justice 
prisons, and jails. 
While the above list of agencies and programs is long, we do not know the extent to
which their servces reach this population. We did not find national data on the
number of such clients served by any of these agencies and their programs. Scope and Methodology

This report describes the experiences and perspectives of people working directly with 
clients in community-based (as opposed to inpatient) programs established specifically 
to treat people with co-occurring MH/SA disorders. 
One impetus for this study was previous studies which we conducted on services to 
homeless people, especially those with mental i1ness 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 service programs. 
A second impetus was the SAMHSA joint demonstration program noted previously. 
In our early discussions with SAMHSA staff, we learned that a report on the first year 
of the demonstration was planned that would address certain aspects of program 
structure, operation, and effectiveness. It would not, however, focus specifically on the 
staff in these programs - the background, experiences and perspectives of those who 
work day-to-day with this difficult population. We learned that this type of 
information was also of interest within SAMHSA and would serve to complement the 
programmatic information coming from the special demonstration. 
, our early reading and discussions with more than 25 experts in the field 
In addition
confirmed that an increasing amount of literature addresses the nature of co-occurring 
MH/SA disorders and treatment approaches, but that there is very little information 
about front-line staff. These experts also expressed interest in this type of 
information. 
In the second phase of the study, we spoke with 71 people in 30 programs, identified
through references in the literature, descriptions of the special demonstration 
programs and other Federal programs, and suggestions from experts. Almost all of 
the programs treat persons with co-occurring MH/SA disorders exclusively, although a 
few also have some clients with mental ilnesses or substance abuse problems only. At 
each program, we spoke with a supervisor or manager, and one or more staff working 
directly with clients in treatment-related activities (as opposed to outreach). Most 
discussions were by telephone; we visited two programs to conduct intervews in 
person. 
2 and are very diverse both demographically 
The programs are located in 20 States
and programmatically. The 28 provider agencies running the programs include: 17 
mental health providers, 3 substance abuse providers, 4 private non-
profit social 
service agencies , 3 hospitals, and a veterans service agency. A quarter of the 
programs were located in metropolitan areas (cities over 500 000), 15 percent in small 
cities or rural areas, and the rest in medium size cities. 
2 Alaska California, ConnecticlI
, Delaware, Florida, Georga, llinois, Indiana, Missouri, Nebraska, New York; 
Ohio, Oklahoma, Oregon, South Carolina, Texas, Vennont, Virgnia, WLSconsill and Wyoming.  . ..
..  . . . ......
We did not explore the funding of these programs in depth. However, we deliberately 
included seven recipients of CSAT-CMHS demonstration funds, and we found two 
programs that receive PATH funding. Other sources of funding reported by the 
managers we talked to were Federal funding from HUD, the National Institute on 
Drug Abuse, CSAT, and Medicaid or Medicare reimbursement; State or county 
mental health or substance abuse funds (some of which may be Federal block grant 
dollars); special State "community support services" funds (one State); client fees; and 
United Way or other private donations. 
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. 
Chart A shows the programs by type, as  CHAT A 
described to us by respondents, and the 
REPONDENT 
respondents by type of job responsibility. 
Readers wil note that the 46  PROGRA  Magcn  Fruo(  Boll 
respondents working directly with clients  Onl  I lio Onl  MgrlF  TOTAL 
front-line" staff) fall into two  6 Residenti  3 . 
categories. Thirty-two people have 
8 Out-Patient 
front-line responsibilities only. Fourteen 
people combine front- 10 Day Tmt 

line duties with  3 .

Pania Hoop. 
supervsion or management. 
5 CI-ty' 
We asked all 71 respondents to describe 
1 Olh 
the clients in their programs
, their goals 
TOTAL 
for clients and how they are trying to 
achieve them, and their success in  COnJus trallL  or  cc tr  fu 
meeting those goals. We asked the 46  Singk room  occu  holdc  mwi.  di  maga 
co17  rn he 
staff with front-
line responsibilities 
specifically, about their prior job 
experience, education, and training. We 
did not verify the information respondents gave us or evaluate these programs. 
We have also issued a companion report entitled "Services to Persons with Co-
Occurring MHiSA Disorders: Program Descriptions" (OEI-05-94-00151), which 
provides descriptions of the 30 programs whose managers and front-line staff we 
intervewed. The combination of this survey analysis and the program descriptions 
provides as complete a picture as possible about issues, successes, and problems in the 
emerging field of treating persons with co-occurring MH/SA disorders. 
We conducted this inspection in accordance with the 
 Standards for Inspections  issued 
by the President's Council on Integrity and Efficiency.  FINDINGS

MOST FRONT-LIN STAF WORK IN NEW PROGRAS. THY HAVE
LIT EDUCATION, TRING
, OR PRIOR EXPERIENCE SPECIFCALY 
RELATED TO CO-OCCUING MENTAL HETH AN SUBSTANCE 
ABUSE DISORDERS. 
Th mljority of front-line staff work in relatively new programs. Half of front-line staff 
have worked clients with co-occurg MH/SA disorders years or less. 
, specifcally, for 
Sixty percent of the  programs  in our sample are 3 years old or less. Only four 
programs are more than 5 years old. Sixty percent of the 46 front- are 
line  staff 
working in programs 3 years old or less. One quarter work in programs that are 1
year old or Jess. 
We asked front-line staff how many years they have worked with clients with co
occurring MH/SA disorders, specifically (as opposed to working with them as part of a 
broader client population). One half said they have worked with this population for 3 
years or less; another 25 percent have worked with them for 4 or 5 years. As a group, 
the 14 people with both management and front-line duties tended to have more years 
experience with these types of clients than strictly front-line staff. 
Most front-line staff report being responsible for case management, couneling of some 
sort or education. They work as part of multi-disciplinary staff teams and most of their 
work is with groups of clients. 
We asked front-line staff to generally describe their job, and where it fit in with the 
jobs of other staff in their programs. 
It is diffcult to cleanly and distinctly describe their job responsibilities because many 
of them are involved in such a variety of activities, and their titles, per se, usually do
not tell the entire story of what they do every 
day. For example, a " case manager 
might be a nurse on a continuous treatment team who besides making 
sure clients get 
the servces they need, administers medications and counsels clients in some capacity. 
We contacted one program director as she was cooking 
Junch with clients; of herself 
and other staff, she said: "We all do everything around here. We cook, we drive the 
van , we go on outings with clients." Thus the following descriptions are meant to 
provide only a general picture of what front-line staff are doing. 
About 60 percent of front-line staff described themselves as case managers (13) or 
counselors (14). Seven of the case managers are people who combine management 
responsibilities with handling a small caseload. We did not ask 
respondents to define
or describe "case management" in their programs in any detail. However we found 
that case managers are the most likely to be dealing with 
individual clients , monitoring  . .
, "

treatment plans and connecting them with other services. We also found that case 
managers may be involved in counseling, education, or social activities. 
The duties that the counselors described ranged from individual and group counseling 
in mental health or substance abuse, to vocational rehabilitation or job counseling, to 
education and, in some cases, involvement in 12-step or 12-step based groups. 
The other 40 percent of respondents include: nurses , most often responsible for 
medication management (under the supervision of a psychiatrist) and education; and 
3 who report being involved in counseling of some sort 
others with a variety of titles
social or recreational activities, or anci1ary services such as transportation. 
Front-line staff spend most of their time with groups of clients. Also, 75 percent 
described working as part of a multi-disciplinary staff team rather than independently.
This may in part account for the variety in terms of job duties, as staff with different 
expertise combine forces in counseling or education sessions  cover for each other 
and participate together in social and recreational activities with clients. Teams may 
consist of only two or three people, or more. They most often are comprised of a 
manager or supervisor (who may also carry a small caseload), case managers 
counselors, nurses, and a part-time psychiatrist; some of the other staff on teams that 
were mentioned included an art therapist, vocational or recreational rehabilitation 
specialists , social workers, mental health aides, and a secretary. 
Despite receiving college degrees in field such as psychology and couneling, few front-line 
staff have been educated or trained specifcally on co-occurrg MH/SA disorders. 
Chart B shows the highest educational  CHAT B

level attained by front-line staff. 
IDGHEST  REPONDEN 
EDUCATIONAL  REORTIG
LEL 
The most common fields in which (N='46) 
people received college degrees are 
Higb school diploma  4 (9%) 
psychology and counseling, including
degr 
rehabiltation counseling, but they also
 Bachelor's  13 (28%) 
received degrees in human services 
Mater's degree  23 (50%) 
, recreation therapy, and 
health sciences
Socin Work: 

organizational communications. In 
Ot 
addition to their degrees, 22 people 
NuISg (R, LPN,  5 (11%)
reported having some sort of special 
LVN 
certifica tion or license, 12 of them for
Other: Psychologit  (2%) 
drug and alcohol counseling. 
3 such as: substance abllse supervisor; panial hospitalization specialist;  bslance  abuse or dual diagnosis specialist; 
recrealionallherapy coordinator; communiry support worker; human services technician; consultant (to a continuous 
treatment team).  , "

As might be expected, we found that the educational level of the 14 people with 
management responsibilities, as a group, was somewhat higher than that of staff with 
front-line duties only. For example, the psychologist falls into that group, and a higher 
proportion of the group has master s degrees. Conversely, the four individuals with 
high school diplomas have front-
line duties only. 
Notably, half of the staff with only front-line duties said they are currently pursuing
additional education, licensing, or certification, from Associate Degrees to PhDs. This 
compares with 2 of the 14 persons with some management duties. 
Eleven respondents revealed that they are in recovery from alcoholism or drug 
addiction. Two of the 11 reported combining supervision with case management; 9 
reported front-line duties only including counseling, social and recreational activities 
or transportation. This group was most likely to report having a high school diploma 
only, although just as many had bachelor s or master s degrees. Four of them have 
experience in business, as well as in social services of some sort. 
About half of the front-line only staff said they have had some training on co-occurring
MH/SA disorders on the job, for the most part in workshops, but they were vague 
about exactly how much training they have had and specifically what was covered. We 
are not convinced that the majority of this training was on co-occurring MH/SA 
disorders, per se. In the managerial group, five people spoke more convincingly of 
attending conferences or other training specifically on co-occurring MH/SA disorders. 
Exosure to national experts in the field led two people to take leadership roles in 
developing programs. One program director, a person who received her Master s in 
Social Work through a grant from the National Institute on Alcoholism and Alcohol 
Abuse, said that 4 years ago  (co-occurring disorders) was a new concept. Very little 
was written and there was no research. I went to (an expert's) workshop and it got
me thinking about what might be done. 
Front-
lin staff credit their job exerience more than their education or training with 
helping them work with clients with co-occurg MH/SA disorders. 
We asked front-line staff what has been most helpful to them in terms of their 
education, training, or job experience in working with clients with co-occurring MH/SA 
disorders. Twenty people, including almost two-thirds of the 32 with front-
line duties 
only, credited their past or present job experience, including "my supervisor " with 
being the most helpful.4 Comments such as "I learn a lot from my co-workers" or 
clients taught me" were common. Also, people who have worked with 
developmentally disabled clients in the past are likely to have found that experience 
helpful in their current jobs.

4 Such comments a/so came from the 
 11  people who reported no pdar job exrience in either the mental health or 
sustane abuse fields, one third of this group of respondents.  , "

Ten people (a fifth of all front-liners) said that their education or, especially, on the 
job training had helped them the most. Others were more critical: "Formal education 
is not preparing people very well for this work " or "Textbook theories don t matter at 
all. What matters is the experience and the desire to help people. 
Eight of the people who are in recovery said that this was most helpful to them. 
Several others mentioned personal characteristics as being helpful: commitment to 
clients or motivation to help people, an outgoing personality, a motivation to learn on 
the job, and even a sense of humor. 
We asked all 71 respondents, managers and front-line staff alike, what education and 
training is needed to work effectively with clients with co-occurring MH/SA 
disorders. 
We heard a strong emphasis everyhere on the need for direct 
experience with
clients. Respondents generally advocate a solid academic grounding in the theories 
and practices of both fields, as well as co-occurring MH/SA disorders per se, but they
clearly believe that nothing surpasses experience on the job. Many 
of them advocate 
practicums that are attached to academic curricula, saying that "there s nothing like
being there. " A minor theme running through these comments seems to be that to be 
effective a philosophy in addition to technical expertise
, one needs to  develop  , to
internalize what one does, to really become invested in the clients and care about 
them. 
While appearing challenged and energed by their jobs at the moment, many front-line 
staff also see burnout as a real threat. 
We asked front-line staff if they had the resources, supervision, and support they need
to do their jobs. We heard some complaints, and quite a few wishes for more staff 
space, or materials, but the vast majority say they are getting the supervision and 
support they need. Sixty percent credited being on a team with giving them the
support they need, and 34 percent credited their supervisor; some credited both. 
Nevertheless, our question  What do staff working with this population need in order 
to prevent burnout?" elicited the most spontaneous and vigorous responses of any 
question we asked. This was clearly a question near and dear to the hearts of these 
respondents. Their answers included: being on a team and having supportive co 
workers (mentioned by all 14 people with both management and front-
line duties),

setting boundaries between personal lives and work, maintaining perspective, making 
sure to take time off and get away, maintaining personal health and stability, getting
good supervision, and having access to education and training.
Many clearly feel pressured and overburdened by the demands of the job. With a lack 
of education and experience in this field, they are feeling their way in trying to find the 
right kind of approach to reach each client, and they are concerned about the lack of 
5 This may be a controversial topic- Some respondenls were not sure aboUllhe importance of being in 
recovery.  progress made by so many clients. One comment expresses the sense of many other
intervews: "  re exhausted but still excited. Yet I see burnout coming. 
TH FIST CHNGE FRONT-LIN STAF FACE IN THIR WORK 
ENONMNT 
IS THT THIR CLIENT HAVE A HOST OF SERIOUS 
ILS AN 
PROBLEMS IN ADDITION TO MENTAL  SUBSTANCE ABUSE. 
We asked all 71 respondents to describe their clients who have co-occurring MH/SA 
disorders. In most cases, their descriptions dovetail with those in the literature of 
clients with severe mental ilnesses, and substance abuse. 
In terms of general demographics, in most programs male clients outnumber females 
by at least two to one , and the majority of clients are in their 20's and 30's. The 
majority are on public assistance
, typically Supplemental Security Income and 
Medicaid. 
In terms of treatment needs, respondents report that their clients have severe, long-
standing ilnesses. The majority are suffering from schizophrenia, and a smaller but 
significant number suffer from major or bipolar depression; a quarter of all 
respondents reported that some of their clients also have personality disorders. 
Clients are using or abusing alcohol (mentioned by 70 percent of respondents), 
cocaine or crack (60 percent), marijuana (40 percent), and heroin (13 percent; a 
number of people commented that heroin use is on the rise in their areas). Polyabuse 
(abuse of two or more substances) is not uncommon. 
Chart C shows more characteristics  CHT C

mentioned, in descending order by 
frequency of mention. Most respondents  CLINT CHCISTCS MEONE 
named two or more of these 
Homelcst rik of bomelesn= 
characteristics. 
Hitory of ares jai; or prn
Dyfunctona
Respondents mentioned other - Pbf)"aica a l abus
characteristics that make treatment  in 
Menta retation

difficult: long histories of disability and
Orgae damage (lier, bra)
deeply entrenched substance abuse;

resistance to treatment (they have 
burned their clinical bridges" by failing 
in numerous treatment programs); and extreme social isolation, with little or no 
support network of family or friends. 
Further complicating treatment for staff, many programs accept clients who are at very 
different levels of functioning, from those with a host of severe impairments and a 
long history of ilness and dysfunction, to those judged to be capable of living and 
6 In contrast
 26  of the  32  front-line (only) workers in this study are female. , "

working in the community with minimal support. A few programs treat persons with
co-occurring MH/SA disorders along with others with mental ilness or a substance 
abuse problem only. One program treats clients who are homeless and living at a 
shelter, others who are on parole, living in the community, and mandated to attend 
and stil others, living in the community, who are clients of the community mental 
health center. Most clients have co-occurring MH/SA disorders, but some have only 
substance abuse problems. 
MA  WI A 
FRONT-LIN STAF HAVE  GOAL FOR CLIENf  LONG-
TERM VIW OF RECOVERY. RELATIV TO SUBSTANCE ABUSE, THY 
URGE CLIENf TO ACHVE ABSTINNCE BUT PRIVATELY DO NOT 
EXPECf MOST OF THM TO ACHVE IT IN TH SHORT TERM. 
We asked aU 71 respondents to describe their goals in working with clients
specifically, what client outcomes they seek to achieve. They mentioned a host of
changes they would like to attain over a long period of time. Eighty percent of 
respondents named at least two goals; 30 percent named four goals. Chart D shows 
the most common responses. 
CHT D

In terms of substance abuse problems 
specifically, most respondents believe 
MEONE 
that in the very long-term, sobriety or  GOAL 
abstinence should be a goal, and say that 
Long term soriety/absence

this is the goal they "preach" to clients.  Intrea independencc, self.:ffticncyj
However, as one program director said:  rIonpincgr 
We don t feel most people are going to  menta stbilty, includig
wiLh medcatins
be abstinent. We assume treatment wil  complice- drig/drggg
Reduce 
be long, term (2 years or more) and Increa. stabilty, better qual. of life
involve a lot of support and intervention Increa self knowedge,undersdig; 
awnes. 
in a lot of arenas.

Incrself=teem, bope

, respondents  thgs.. 
In discussing goals u. Rannd  ons we uto  ab th ne!iz" , coliwi
repeatedly emphasized that for most of  r=a1 an  iI  00"' trgg 
their clients  recovery" is a relative term 
and wil take years to achieve. When 
asked to name the most important
. personal attributes staff need to be effective with these clients , the one most 
frequently named (by half of all respondents) was "patience. 
FRONT-LIN STAF DESCRffE TH APPROACH THY TAK TO HELP 
CLIENf AS HOLISTIC, INIVUALIZED, FLXILE, OR CRTIVE 
WI 
1HT 
THY SAY  ESTABLISHING TRUST  CLIENT IS KEY, BUT 
VERY DIFICUT TO DO. 
We asked all 71 respondents, managers and front-line staff alike, to describe their 
approach to working with clients with co-occurring MH/SA disorders. Given the great  " " , "

variety in client disabilities, histories, and levels of functioning, it is not surprising to 
learn that approaches are being adapted in a number of ways. 
Almost two-thirds of all respondents report taking a "holistic" approach in tring to address 
many client needs besides those related to mental illness and substance abuse. Case 
management is used in many programs to connect clients with services. 
of clients through 
In addressing the  mental health and substance abuse problems 
counseling and education, respondents emphasize compliance with medications 
problem solving, and "learning ways to avoid drinking and drugging." They also try to
build self esteem and a sense of hope, and help clients learn to live independently in 
the community.
Respondents also mentioned other services their clients need, especially in terms of 
long-term recovery. 
Sixty percent of all respondents said that their clients need housing - not only 
Housing: 
a roof over their heads, but more importantly, clean, safe, and affordable housing 
located in sober living environments, often with supportive services of some kind 
available. Many of their clients are living in substandard housing in poor 
neighborhoods where drug abuse is prevalent. In such housing, people said, clients 
are almost guaranteed to relapse no matter how effective a treatment program is. 
Social or recreational activities, including volunteer activities  vocational education or 
and 
A quarter of all respondents said that clients need such activities 
Job-related services: 
to facilitate recovery, because they provide structure which is critical to achieving 
mental stability and sobriety. We heard many comments such as: "Boredom leads to 
substance abuse;  (Clients) need structure and something to do;" and  You need to 
fil the vacuum that drugs filed . 
Aftercare or relapse prevemion programs, long term mental health services, and programs 
Each of these was 
designed specifcally for clients with co-occurrng MHISA disorders: 
mentioned as a long-term need of clients by 15 percent of all respondents. 
Case management is the most common mechanism for connecting clients to services 
both in and outside these programs. Two thirds of all respondents reported that case 
management is a part of their program.
Within the strctured activities of their programs, respondents are tring to be flexble and 
adaptig their approach to meet the individual needs of clients. 
creative in 
Almost half of all respondents used the word "
individualized" to describe their 
approach to clients, trying to "blend and adjust to each individual's needs" in order to 
be effective; 25 percent named creativity and flexibility as personal attributes needed 
to be effective with clients with co-occurring MH/SA disorders: "You must learn to do 
things differently, follow your instincts and adapt your approach." One of the most  , "  , " " "
difficult challenges is that "some (clients) need a certain toughness, others need
nurturing.
Adaptations can be as simple as going for a walk to counsel a client who is having 
difficulty sitting sti1, or much broader. For example, we heard comments that while 
structure and boundaries are important for clients, rigid adherence to rules and 
schedules is often not effective. Most respondents reported that if clients 
violate rules 
regarding abstinence  they can lose privileges , but they don t get thrown out 
automatically. We use it as a therapeutic tool." Relapses are discussed individually 
and in groups to increase clients' understanding of the causes and consequences of 
relapses and how to avoid them in the future. "Slips are allowed " said another 
director  with gradual attempts at shaping of behavior. 
Staff may minimize confrontation, simplify concepts, or proceed very slowly for clients 
who have a short attention span, are paranoid or delusional , iliterate, mentally 
retarded, or otherwise have difficulties with abstract thought. One of the more 
common activities in which these kinds of adaptations are made is 12-step groups. 
Many staff report that they routinely seek client feedback on the subjects covered in
, and recreational or social activities. For the most 
education or counseling sessions
part, feedback is verbal and informal, although some programs do written client 
surveys periodically. Almost uniformly, respondents view client input as valuable if not 
crucial in running effective programs with active client participation. 
The use of multi-disciplinary staff teams also stimulates flexibility and creativity as staff 
share their expertise, experience, and perspectives to come up with ideas about ways 
to structure program activities or reach individual clients. 
Front-line staff view building trut and a personal relationship with clients as ke to 
makig progress but 
very difcult to do. 
We asked front-line respondents how well they know clients and if it is important to 
establish a personal relationship with clients. We found that "building a personal 
relationship of trust and respect" was the number one factor they mentioned when 
asked to describe "what works" to help clients. However, many would probably agree 
with the supervisor in a residential program who said that this is "both the most 
important and the most difficult thing" of all to do. 
To overcome cultural and other barriers between themselves and clients
, especially 
suspicion or lack of trust that many clients exhibit, requires a respect for clients as 
individuals, and "time, consistency, and a certain chemistry." Half of all 71 
respondents said that being "caring,  non-judgmental " and "respectful" towards clients 
are attributes of effective staff. Working in teams is also viewed as a plus, as 
members share their perspectives on client behavior and ways to break through 
barriers, and take over for each other in difficult situations: "I need the team. There 
are times I just can t deal with a client, and someone else can step in.  , "

In terms of activities, music or art therapy, social activities, and recreation are touted
as ways of building bridges between clients and staff. Some say that men-only or
women-only groups are the best way to discuss certain sensitive issues - sexual abuse
for example.
Success in creating relationships is mixed. As a group, case managers are the 
most
likely to say that they know their clients we1l, especially in "their world" (their homes
their family and friends). Several people commented that case managers are the most
likely to get closer to clients since they help them with many needs
, see clients mostly
in their homes or the community, and work with them for a long time. Also: "
Often
the case manager is the only person (clients) know " and  Lots of what dua1ly

diagnosed people do drives people away. Case managers wil stick around.
Other staff, especia1ly counselors, are less likely to know clients we1l, or commented
that client distrust or dysfunction makes it difficult to establish a relationship. Some
also are unsure about how to balance professionalism and friendship with clients.
FRONT-LIN STAF HAVE NO SINGLE OPINION ABOUT "WHT WORK"

HE 
TO  CLIENT. THY DEFIN SUCCES IN RELATIV, SUBJECTIV
TERMS, AN TAK A LONG-TERM VIW.

Views of front-line staff on "what works , a question that many experts
" to help clients

urged us to ask, are many and varied: building a personal relationship (mentioned
previously), being slower and more concrete with clients, providing levels or a
continuum of servces, working with clients over a long period of time, individualizing
one s approach, providing activities to replace substance use, providing "structure" or
boundaries " and being flexible, creative or eclectic in approach.
Taking a broader view, we asked a1l 71 respondents how successful they are in
achieving the goals they have set forth for clients. We found that few programs
7 or have data on client outcomes. Therefore
conduct formal evaluations
, most views
of success are highly subjective.
Views. were mixed at best. In terms of the managers, a third said their programs were
too new to judge success or have had little or no success
, 25 percent labe1led their
programs a success, and the rest said that their programs are able to make some
progress with some clients, or that attendance and participation rates are good.
In terms of front- , only two labeled their programs an unqualified success.
line staff
7 Th 
 program with the most formalized evaluation efforts were two affliated with hospitals and a few others with
some Federal ftmding from HUD, the National Instillle on Dntg Abuse, or the CSAT-CMHS demonstrations. The
director of one agency, who has done some outcome 
 'alllation.  said that a recent cut in their Federal grant had led to
the elimination of the evaluation component of the program. Many programs do rOllinely seek diem feedback, however
either through periodic wnlfen surveys or discllssions. , "  , "

We heard about high drop-out rates in some programs
, as much as 50 percent, and
many people said that only clients who are motivated or "wiling to change " who 
stayed with the program, were likely to make progress: "  re able to touch 40 
percent of our clients " and  Half drop out, but the program is pretty successful for 
the others." Respondents reportedly have a very difficult time helping clients who are 
the most severely ill , have borderline personalities
, or are crack addicts. 
Over 50 percent do report taking some satisfaction from seeing a few clients make 
progress, or many clients take "baby steps" towards recovery over time: reduced 
substance use, housing stability and the like. However many people would probably 
agree with this member of a continuous treatment team who said 
I know that any
success will be a long and lengthy process. , "

RECOMMENDA TIONS
PHS SHOUL DEVELOP A PLA TO INCRE KNOWLDGE ABOUT CO 
OCCUING  HETH AN 
MENTAL  SUBSTANCE ABUSE DISORDERS
AN THIR TRTMNT 
AMONG CLINICIAS, OTHR PROFESIONAL
AN 
SERVICE PROVIERS.
This report highlights the tremendous challenges facing staff who work directly with
persons with co-occurring MH/SA disorders. It reinforces the descriptions in the
literature of the degree of illness and dysfunction of the clients, and it reveals the lack
of appropriate education, training, and experience of front-line staff. In terms of
approaches, it supports the view of one expert we spoke with that  right now
everyone is fumbling around locally with trial and error.
The PHS funds many programs, noted in the Background, that do or could serve
persons with co-occurring MH/SA disorders and which routinely provide technical
assistance or training to their grantees. Some have begun to respond to increasing
demand from grantees; we understand that the PATH program, the mental health
servces block grant program, and Health Care for Homeless all provided training on
co-occurring MH/SA disorders at regional and national conferences in FY 
1994.
The PHS also funds education and training programs for clinicians and other
professionals. Two respondents in this study benefitted from such programs. One
received her master s degree thanks to a grant from the National Institute on Alcohol
Abuse and Alcoholism. The other, a psychiatrist, reported receiving a National
Institute on Drug Abuse career award in this field; he noted that an added plus of this
award is that it allows him to do research related to his work. Relatively recent
educational efforts include the issuance by the Center for Substance Abuse Treatment
of a special Treatment Improvement Protocol on co-occurring MH/SA disorders, and
the development by the National Institute on Drug Abuse of an educational videotape.
We applaud these efforts. However we also point out that they do not appear to be
coordinated, either between the various offices which have undertaken them or with
other Federal agencies or other entities who deal with this population. Given the
growing number of clients with co-occurring MH/SA disorders, their degree of ilness
and dysfunction, and the inexperience and lack of proper training of the staff who help
them, we call for PHS to develop a plan to use its existing arsenal of education
training, and technical assistance resources, and to provide Federal leadership with
entities outside PHS, to increase knowledge and understanding of co-occurring MH/SA
disorders among professionals and programs that serve this population.
The plan should encompass the development of academic curricula, training materials
for those already in the field, and technical assistance materials. Many experts we
spoke with for this study ask for strong Federal leadership in this arena. One of the most highly respected said, for example: "Training programs are not teaching people 
to do this (provide integrated treatment). This is a desperate situation. We have to 
train the current workforce, and we have few experts to do it. It looks just as bad for 
the future. I can t think of one single clinical training program doing this." Also, a 
meeting last year of the National Association of State Alcohol and Drug Abuse 
Directors, National Association of State Mental Health Directors, National Association 
of Counties, and SAMHSA resulted in a lengthy recommendation, not yet 
implemented, that SAMHSA mount a strong technical assistance and training effort 
on co-occurring MH/SA disorders. 
We suggest that in developing a plan, PHS col1aborate not only with other 
departmental programs serving this population, especial1y the Health Care Financing 
Administration (Medicaid), but with State and local grantees, national associations 
professional organizations, experts, researchers, and clinicians and practitioners who 
have direct experience with this population. 
Col1aboration with other Federal agencies that serve this population is especial1y 
important, we think: with the Departments of Veterans Affairs, Housing and Urban 
Development, and Justice, and with the Social Security Administration. One especially 
notable cooperative Federal effort newly underway is the mental health and substance 
abuse work group under the auspices of the Interagency Council on the Homeless 
Priority: Home! The Federal 
charged with developing an action plan in connection with 
Some of the action steps initial1y developed 
Plan to Break the Cycle of Homelessness. 
by this work group are consistent with, and indeed support, our recommendation here. 
We also suggest that PHS use existing technology (for example, the Internet 
teleconferencing, videotapes) to produce and disseminate training and educational 
materials at a reasonable cost. Curricula and materials should be 
disseminated not 
only via universities , but through the community col1ege network. Also, resource 
centers established in connection with specific departmental programs (the Community 
Support Program is one example) are a useful conduit for such information.
We hope that PHS wil1 find the information we provide in this report useful in
developing their response to this recommendation. 
AGENCY COMMNT 
The Public Health Service concurred with our recommendation. Their comments are 
attached as Appendix A. They also submitted a number of technical comments on 
which we have based some revisions to the text. APPENDIX A 
AGENCY COMMNT  ( ?

DEPARTM.E:-T OF HEAl.TH &. HCM,A,,' SER"lCES  ?uolic HeaM Service 
4-1-.  Memorandum 
MAY 3 0 199
Dae 
Assistant Secretary for Health
From 
Of f ice of Inspector General (OIG) Draft Reports" Services to
Subjec 
Persons with Dual Disorders: Provider Perspectives
OEI-OS-94-001S0 and " Services to Persons with Dual Disorders: 
Program Descriptions, " OEI-OS-94-001S1 
Inspector General, OS
Attached are the PHS comments on the OIG draft reports on
Services to Persons with Dual Disorders, We agree that a plan
for increasing knowledge about co-occurring mental
health/substance abuse disorders and their treatment is
critical to improving services and service delivery to this
consideration. 
population. Our comments describe PHS' efforts to address'
this issue, In addition, we offer technical comments on both
reports for your 
(C 
Philip R. Lee, M.
Attachment  COMMENTS OF THE PUBLIC HEALTH SERVICE (PHS) ON THE OFFICE OF 
INSPECTOR GENERAL (OIG) DRAFT REPORTS. " SERVICES TO PERSONS 
WITH DUAL DISORDERS: PROVIDER PERSPECTIVES. " OEI-05-94-00150 
AND 
SERVICES TO PERSONS WITH DUAL DISORDERS: PROGRA 
DESCRIPTIONS. " OEI-05-94-00151 
GENERAL COMMENTS
The OIG draft reports provide the results of the OIG' s survey
of programs that serve people with co-occurring mental health
and substance abuse disorders  (co-occurring MH/SA disorders) 
and describe the programs and the experiences of program staff 
in providing services to this population. 
The reports recognize the broad social consequences (i.
homelessness 
, violence, crime, the spread of HIV/AIDS
tuberculosis 
, etc. ) of not adequately treating people who have 
a history of substance abuse and mental illness. The personal
devastation and individual treatment needs should not be
minimized; but the overall impact of a person's illness must
also be viewed in the context of his or her children, family
and community. Where substance abuse and mental health
problems are not recognized and treated, there is increased
stress on family, friends, and care givers. We believe that
improving collaboration and the exchange of information among
researchers 
, program staff, and patients and their families 
could help to alleviate these social consequences. 
The reports also discuss ways to encourage innovative
approaches to the development of training programs and
curricula. Federally-sponsored educational programs usually
are designed for one profession or another; however,
profession-
specific approaches are not necessarily appropriate 
for complex pathologies. Educational programs developed to
train clinicians, other professionals and service providers 
should be designed to include both traditional and alternative
therapies. In 
addition, it is essential that people affected 
by co-occurring MH/SA disorders--and people at risk for co 
occurring MH/SA disorders--be educated as well. Therapies
have a much greater likelihood of being successful when people
who suffer from co-occurring MH/SA disorders and their
families are active participants in developing treatment
modalities. 
Finally, the reports stress the importance of training;
however, we believe the reports should also acknowledge the
importance of evaluation. Unless we understand what effect
the training, the work of the therapists, and the availability
of funding is having on the amelioration of the problem, we
will continue to operate in the dark. While this aspect is
painful because it uses some of the resources (fiscal and
clinical) that could be used to treat patients
, it is important to find out if the patients are getting well 
better, establish how many of them there are , how many there
are a year or two after treatment , what treatment is
effective 
, and exactly how the Federal programs are
cooperating (i. e., how Federal funds are being used) 
OIG RECOMMENDATION 
PHS should develop a plan to increase knowledge about 
dual disorders and their treatment among clinicians, 
other professionals, and service providers. 
PHS COMMENT 
We concur. Individuals with co-occurring MH/SA disorders
present unique challenges for the alcohol/drug abuse/mental
health 
(ADM) services field. We agree that a plan for 
increasing knowledge among service providers in the ADM 
specialty sector and in primary care settings is critical to 
improving services and services delivery to this population. 
We also agree that all stakeholders, including consumers and 
their families, should be included in the development and 
implementation of such a plan. 
The plan should encompass the development of academic 
curricula, training materials for those already in the 
field, and technical assistance materials. 
PHS COMMENT 
We concur. However , before developing new curricula we should 
review what currently exists. Some efforts have already been
made in this area. The National Institute on Alcohol Aybuse
and Alcoholism and the National Institute on Drug Abuse have 
funded curriculum development and faculty development
proj acts. 
The Substance Abuse and Mental Health Services Administration 
(SAMSA) has also begun several efforts to improve services 
for individuals with co-occurring MH/SA disorders. An Action 
Plan (Attachment I) has been drafted which addresses the need 
to improve provider knowledge within current agency programs. 
In addition, the SAMSA National Advisory Council is planning
a national conference on this issue which is expected to yield 
recommendations for action in several substantive tracks, 
including education and training. SAMSA Centers are also 
engaged in efforts designed to learn more about effective 
service provision for this population and to disseminate that 
information to the field. (See Attachment II for activity
descriptions. )  In addition, SAMSA' s Center for Substance Abuse Treatment 
(CSAT) has been chairing an Interagency Committee on education 
and training as part of its training initiatives. There is a 
need for skills-based clinical training which is not 
specifically mentioned in the OIG reports' recommendations. 
CSAT awarded a contract to Lewin-VHI to develop a report on 
training needs. 
Also, SAMSA' s Center for Mental Health Services (CMHS) , in 
collaboration with CSAT , is planning a training curriculum 
that could be used for in-service training of an array of 
service providers for homeless populations and which focuses 
occurring disorders. 
specifically on persons with co-
In the development of training initiatives it will be 
important to collaborate with the professional organizations 
which are developing practice guidelines on the appropriate 
to be 
treatment for these patients. This does not appear 
mentioned in the OIG report. In addition, training materials 
must include the development of academic curricula for health
professionals.
PHS should collaborate with other BRS agencies,
statel local grantees, national 
associations, professional
organizations, experts, researchers, clinicians and other 
s Affairs,
Federal agencies (the Departments of Veteran' 
Housing and Urban Development, and Justice, and the 
Social Security Administration) and consider 
recommendations made by existing reports such as 
"priority: Home! The Federal Plan to Break the Cycle of 
Homelessness. "
PHS COMMENT 
We concur. Coordination of existing resources across HHS 
would benefit persons with co-occurring disorders. Perhaps an 
HHS Coordinating Group on Co-Occurring Disorders could serve
this purpose. 
However, there are already coordinating groups 
in HHS whose focus includes persons with co-occurring 
AIDS and persons who are
disorders - such as persons with HIV 
homeless. 
We would like to point out that the Department of Veteran 
Affairs is represented on the SAMSA National Advisory Council 
that is planning the national conference referred to above.
SAMSA will make every effort to include appropriate Federal 
Agencies in the planning process and obtain their
participation in the conference. 
SAMSA will also disseminate 
any recommendations resulting from the conference to these 
Federal Agencies and work with them to implement the  recommendations. 
land 
As noted above in our comments on recommendations  2, we 
concur that collaboration with professionals in the field is 
necessary to develop the appropriate training materials. 
PHS should use existing technology (e.g. rnternet,

teleconferencing, videotapes) to produce and disseminate

training and educational materials through universities,

community college network, and resource centers.

PHS COMMENT

We concur. We would encourage  producing and disseminating
information through the use of both traditional and innovative 
means of knowledge transfer.