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. 

Jit 

:J.cf)d'za 

JU GffBS BROWN 

Inspector General 

JU 1995 

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 informs the Secretary of HHS of program and management problems and recommends courses to . correct them. OFFICE OF AUDIT SERVICE 

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. 

OFFICE OF EVALUATION AN 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'. 

-1 

rtla 

JU GffBS BROWN 

Inspector General 

JU 1995 

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 cooccurring MH/SA disorders are not addressed in most higher education or on-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 frontliners 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 cooccurg 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€

EXECUIV SUMY€

INODUCTON. . . . . . . . . . . . .. 1€

FININGS. . . . . . . . . . . . . . . . . . . 5€

. Background and experience of front-line staff. . . . . . . . . . . . . . . . . . . . . . . . . . 5€

. Characteristics of their clien ts ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 

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 milion persons suffer from co-occurring mental health and substance abuse (MH/SA) disorders. 

The literature strongly emphasizes the heterogeneity of this population in terms of 

tyes 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 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. 
The Substance Abuse and Mental Health SelVices Administration (SAMHSA) has many 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, 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 SelVices Administration€

funds the Health Care for the Homeless Program and Ryan White programs for€ persons with HIV/AIDS. The Indian Health SelVice 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. The Department of Justice deals with this population via the courts 

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. 

In addition, our early reading and discussions with more than 25 experts in the field 

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. 

The programs are located in 20 States2 and are very diverse both demographically 

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 

respondents by type of job responsibility. 

Readers wil note that the 46 

respondents working directly with clients 

front-line" staff) fall into two 

categories. Thirty-two people have 

front-line responsibilities only. Fourteen 

people combine front-line duties with 

supervsion or management. 

We asked all 71 respondents to describe 

the clients in their programs, their goals 

for clients and how they are trying to 

achieve them, and their success in 

meeting those goals. We asked the 46 

staff with front-line responsibilities 

specifically, about their prior job 

experience, education, and training. We 

REPONDENT 

PROGRA Magcn Fruo( Boll 

Onl I lio Onl MgrlF TOTAL 

6 Residenti 3 . 

8 Out-Patient 

10 Day Tmt 


Pania Hoop. 3 .


5 CI-ty' 

1 Olh 

TOTAL 

COnJus trallL or cc tr 

Singk room occu hold wi di maga fu co17 rn he cm. 

did not verify the information respondents gave us or evaluate these programs. 

We have also issued a companion report entitled "Services to Persons with CoOccurring 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, specifcally, for years or less. 

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-€line staff are 

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 cooccurring 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 

others with a variety of titles3 who report being involved in counseling of some sort 

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 

level attained by front-line staff. 

The most common fields in which€

people received college degrees are 

psychology and counseling, including€

rehabiltation counseling, but they also


received degrees in human services 

health sciences, recreation therapy, and 

organizational communications. In 

addition to their degrees, 22 people 

reported having some sort of special 

certifica tion or license, 12 of them for€

drug and alcohol counseling. 

CHAT B


IDGHEST REPONDEN 

EDUCATIONAL REORTIG LEL (N='46) 

Higb school diploma 4 (9%) 

Bachelor's degr 13 (28%) 

Mater's degree 23 (50%) 

Socin Work: 


Ot 

NuISg (R, LPN, 5 (11%)€

LVN 

Other: Psychologit (2%) 

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, one needs to develop a philosophy in addition to technical expertise, 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 coworkers (mentioned by all 14 people with both management and frontsetting boundaries between personal lives and work, maintaining perspective, making 

line duties),


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 

PROBLEMS IN ADDITION TO MENTAL ILS AN 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, longstanding 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 

named two or more of these 

characteristics. 

Respondents mentioned other€

characteristics that make treatment 

difficult: long histories of disability and€

deeply entrenched substance abuse;


resistance to treatment (they have 

burned their clinical bridges" by failing 

CLINT CHCISTCS MEONE 

Homelcst rik of bomelesn= 

Hitory of ares jai; or prn Dyfunctona - Pb)"icaal abus€

Menta retation


in fa €

Orgae damage (lier, bra)€

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. 

FRONT-LIN STAF HAVE MA GOAL FOR CLIENf WI A LONGTERM 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. 

In terms of substance abuse problems 

specifically, most respondents believe 

that in the very long-term, sobriety or 

abstinence should be a goal, and say that 

this is the goal they "preach" to clients. 

However, as one program director said: 

We don t feel most people are going to 

be abstinent. We assume treatment wil 

be long, term (2 years or more) and€

involve a lot of support and intervention€

in a lot of arenas.


In discussing goals, respondents 

repeatedly emphasized that for most of 

their clients recovery" is a relative term 

and wil take years to achieve. When 

asked to name the most important€

CHT D


GOAL MEONE 

Long term soriety/absence


Intrea independencc, self.:ffticncyj€

roping€ Incr menta stbilty, includig€ complice- wiLh medcatins€

Reduce drig/drggg€ Increa. stabilty, better qual . of life€

Increa self knowedge,undersdig; 

awnes. 

Incrself=teem, bope


. Rand we to ab iz thgs.. un on iI th ne!", coliwi r=a1 an su 00"' trgg 

. 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 

THY SAY 1HT ESTABLISHING TRUST WI 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. 

In addressing the mental health and substance abuse problems of clients through 

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. 

Housing: Sixty percent of all respondents said that their clients need housing - not only 

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 and vocational education or 

Job-related services: A quarter of all respondents said that clients need such activities 

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 designed specifcally for clients with co-occurrng MHISA disorders: Each of these was 

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 

creative in adaptig their approach to meet the individual needs of clients. 

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€

education or counseling sessions, and recreational or social activities. For the most 

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"


TO HE CLIENT. THY DEFIN SUCCES IN RELATIV, SUBJECTIV€

TERMS, AN TAK A LONG-TERM VIW.


Views of front-line staff on "what works" 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€

, a question that many experts€

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€

conduct formal evaluations7 or have data on client outcomes. Therefore, 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-line staff, only two labeled their programs an unqualified success.€

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 MENTAL HETH AN 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 

charged with developing an action plan in connection with Priority: Home! The Federal 

Plan to Break the Cycle of Homelessness. Some of the action steps initial1y developed 

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 
( ?

4-1-. 

Dae 

From 

Subjec 

DEPARTM.E:-T OF HEAl.TH &. HCM,A,,' SER"lCES ?uolic HeaM Service 

Memorandum 

MAY 3 0 199€

Assistant Secretary for Health€

Of f ice of Inspector General (OIG) Draft Reports" Services to 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€

population. Our comments describe PHS' efforts to address'€

this issue, In addition , we offer technical comments on both€

reports for your consideration. 

(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 cooccurring 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

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) 

there€

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 

specifically on persons with co-occurring disorders. 

In the development of training initiatives it will be 

important to collaborate with the professional organizations 

which are developing practice guidelines on the appropriate 

treatment for these patients. This does not appear to be 

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 

Federal agencies (the Departments of Veteran' s Affairs,

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 disorders - such as persons with HIV AIDS and persons who are 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. 

As noted above in our comments on recommendations land 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.