Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

SERVICES TO PERSONS WITH


CO-OCCURRING MENTAL HEALTH


AND SUBSTANCE ABUSE DISORDERS


PROGRAM 

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DESCRIPTIONS 

JUNE GIBBS BROWN 

Inspector General 

JUNE 1995 

OEI-05-94-00151 
OFFICE OF INSPECTOR GENERAL 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services’ (HHS) 

programs as well as the health and welfare of beneficiaries served by those programs. This 

statutory mission is carried out through a nationwide network of audits, investigations, and 

inspections conducted by three OIG operating components: the Office of Audit Services, the 

Office of Investigations, and the Office of Evaluation and Inspections. The OIG also informs 

the Secretary of HHS of program and management problems and recommends courses to 

correct them. 

OFFICE OF AUDIT SERVICES 

The OIGS Office of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors in 

carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the Department. 

OFFICE OF INVESTIGATIONS 

The OIGS Office of Investigations (01) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 

unjust enrichment by providers. The investigative efforts of 01 lead to criminal convictions, 

administrative sanctions, or civil money penalties. The 01 also oversees State Medicaid fraud 

control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 

OFFICE OF EVALUATION AND INSPECTIONS 

The OIGS Office of Evaluation and Inspections (OEI) conducts short-term management and 

program evaluations (called inspections) that focus on issues of concern to the Department, 

the Congress, and the public. The findings and recommendations contained in these inspection 

reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 

and effectiveness of departmental programs. 

This report was prepared under the direction of William Moran, the Regional Inspector 

General for the Office of Evaluation and Inspections, and Natalie Coen, Deputy Regional 

Inspector General, Office of Evaluation and Inspections, Region V. Participating in this 

project were the following people: 

Region V Headquarters 

Barbara Butz David Wright 

Nora Lynn 

To obtain a copy of this report, call the Chicago Regional Office “at312/353-4124. 
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TABLE OF CONTENTS


PAGE


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


PJWGRAMIXS€ CROONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 

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


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


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


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


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


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


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


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


PURPOSE 

Describe 30 programs that serve people with co-occurring mental health and substance 

abuse disorders in a community setting, 

BACKGROUND 

The National Comorbidity Survey, a large general population survey conducted from 

1990to 1992, found that53 percent ofrespondents with alcohol abuse or dependence 

over their lifetime also had a mental disorder over their lifetime, while 36 percent had 

a lifetime illicit drug use disorder. Fifty-nine percent of the respondents with a history 

of illicit drug abuse or dependence over their lifetime also had a mental disorder over 

their lifetime, and 71 percent had a alcohol use disorder over their lifetime. In any 

given year, Survey data reflect that an estimated 7.6 to 9.9 million persons with cooccurring mental health and substance abuse (MH/SA) disorders.l 

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

types of mental disorders, levels of involvement with alcohol and other drugs, and 

degree of functioning. People with these co-occurring disorders can be very difficult to 

treat, with chronic and severe medical, social, and emotional problems and particular 

vulnerability to relapse. Few receive integrated treatment in a single setting, from a 

single clinician who addresses both disorders at the same time. Yet if treated for only 

one disorder, response to treatment is likely to be poor. 

The broad social consequences of failing to adequately treat this population include 

hopelessness, violence, crime, the spread of HIV/AIDS, tuberculosis, and sexually 

transmitted diseases, with their attendant demands on hospital emergency rooms and 

the public welfare and criminal justice systems. 

l%u~ams and Activities for Persons w“th Co-Occuning MH/SA Dtiorders 

In the Department of Health and Human Semites (HHS), the Public Health Service 

funds many services and activities relevant to this population. 

The Substance Abuse and Mental Health Services Administration (SAMHSA) has many 

programs that are directly or indirectly targeted at people with co-occurring MH/SA 

disorders. The national advisory council of SAMHSA has a working group on Services 

1 Since NCS data repect on~ the household population ages 15-54, a true picture of the magnitude of this problem 

must rejlect an additional .l million institutional populatio~ .1 million homeless, .05 million youth age 0-14, and .4 to 

.6 million adults age 55 or ove~ for a totaI estimated 8.3 to 10.8 million individuals. 

1 
Integration which is currently focusing on this issue. A SAMHSA work grouphas 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 Hopelessness (PATH) is 

a formula grant program to States and territories with a specific legislative mandate to 

se~e persons with co-occurring MH/SA disorders. Funded at $29 million in Fiscal 

Year (FY) 1994, PATH provides mental health and other services to homeless 

individuals and at-risk populations that are severely mentally ill or have co-occurring 

MH/SA disorders. Secondly, a demonstration program for homeless individuals with 

co-occurring MH/SA disorders is overseen jointly by the Center for Mental Health 

Services (CMHS) and the Center for Substance Abuse Treatment (CSAT). Sixteen 

providers received grants in September 1993 totalling $4 million to develop and test 

models of effective assessment and intervention for this population. In the second 

year, several providers will receive continuing grants to undertake a formal evaluation 

of their specific service delivery modalities. 

Other SAMHSA programs include the mental health services block grant ($278 

million for FY 1994) and the substance abuse prevention and treatment block grant 

($1.1 billion in FY 1994). Nine Access to Community Care and Effective Services and 

Supports demonstration grants ($19.4 million) are testing services integration 

approaches for persons with severe mental illnesses and/or substance abuse. The 

Community Support Program has funded demonstration projects on persons with cooccurring MH/SA disorders. 

Elsewhere in HHS, the National Institutes of Health fund research and services 

demonstrations through the National Institutes of Mental Health, Drug Abuse, and 

Alcohol Abuse and Alcoholism. The Health Resources and Services Administration 

funds the Health Care for the Homeless Program and Ryan White programs for 

persons with HIV/AIDS. The Indian Health Service funds services for American 

Indians and Alaska Natives. The Health Care Financing Administration funds 

Medicare and Medicaid for health care and related services. The Social Security 

Administration funds the Social Security Disability Income and Supplemental Security 

Income programs. 

Outside HHS, the Department of Veterans Affairs and the Department of Housing and 

Urban Development (HUD) both deal with this population in their homeless as well as 

other programs. So does the Depatiment of Justice via the courts, prisons, and jails. 

While the above list of agencies and programs is long, we do not know the extent to 

which any of their services actually reach people with co-occurring MH/SA disorders. 

We did not find national data on the number of such clients served by any of these 

agencies and their programs. 

2

Scope and Methodology 

This study follows others we conducted on services to homeless people, especially 

those with mental illness or substance abuse, and community mental health services. 

In those studies, respondents pointed to persons with co-occurring MH/SA disorders, 

specifically, as underserved both in homeless and traditional semice programs. 

This report is a companion to another report (“Services to Persons With Co-occurring 

MH/SA Disorders”, 0EI-05-94-O0150) which describes the experiences and 

perspectives of supervisors or managers, and staff who work directly with clients in 

treatment-related activities. The programs are all community-based (as opposed to 

inpatient) and were established specifically to treat people with co-occurring MH/SA 

disorders. In our early discussions with SAMHSA staff, we learned that information 

about front-line workers was of interest and would complement the programmatic 

information coming from the CSAT-CMHS demonstration program mentioned above. 

This report describes the 30 programs in which the 71 respondents work. At our exit 

conference at SAMHSA on the first report, staff expressed interest in learning about 

the programs that these respondents work in. Hence we decided to produce this 

companion report. 

We identified these 30 programs through references in the literature, descriptions of 

the special demonstration programs and other Federal programs, and suggestions from 

experts. Almost all of them treat clients with co-occurring MH/SA disorders 

exclusively, although a few also have some clients with mental illnesses or substance 

abuse problems only. 

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

and programmatically. Twenty-five percent are in metropolitan areas (cities over 

500,000), 15 percent in small cities or rural areas, and the rest in medium-sized cities. 

The providers running the programs include mental health providers, substance abuse 

providers, private non-profit social service agencies, hospitals, and a veterans service 

agency. Seven are recipients of CSAT-CMHS demonstration funds, and two receive 

PATH funding. 

Though we did not delve deeply into the origins of these programs, our strong 

impression is that the major impetus in their development was the recognition by key 

staff that this segment of their client population was growing, and that their needs 

were not being adequately met by existing services. 

We conducted this inspection in accordance with the Standards for Inspections issued 

by the President’s Council on Integrity and Efficiency. 

2 Alaskq California Connec~icu~Delaware, Florida Geor@ I1h%ok,Indian~ A4issou~ Nebraskq New York 

Ohio, Oklahom~ orego~ South Caroling TL=w.s,Vermont, Viiiq W~consitq and Wyoming. 

3 
PROGRAM DESCRIPTIONS


The following information comes from discussions with 71 managers and front-line 

staff who work in 30 programs, located in 20 States, designed specifically to serve 

persons with co-occurring MH/SA disorders. Our primary focus in these discussions 

was on respondents’ experiences and perceptions about working with clients with cooccurring MH/SA disorders, rather than on their programs per se. However, in order 

to have a context in which to understand their comments, we asked respondents to 

briefly describe certain aspects of the structure and operation of their programs. 

These descriptions are best understood by reading them along with our companion 

report entitled “Services to Persons with Co-occurring MH/SA Disorders: Provider 

Perspectives” (OEI-05-94-O0150), which presents an analysis of the responses of 

managers and front-line staff to our survey on how they serve this population. The 

combination of that survey analysis and these descriptions provides as complete a 

picture as possible of issues, successes, and problems in the emerging field of treating 

persons with SA/MH disorders. 

These programs include residential programs, outpatient programs, day treatment or 

partial hospitalization programs, community treatment team programs, and a single 

room occupancy hotel with a day manager funded by a community mental health 

center (CMHC). We present a general description of four aspects of each program: 

structure, funding, clients, and services. The information reflects what our respondents 

told us - and as much as they told us. We did not attempt to veri& their comments, 

review program materials, or evaluate these programs in any way. However, since 

little is known about programs that work specifically with this population, we believe 

that this information will be of interest to people in the field. 

By way of introduction, we note that respondents share the same broad goal for their 

clients, namely stabilization and a better quality of life. Furthermore, they view 

“recovery” as a relative term, and expect it to occur gradually over a long period of 

time. What is interesting to see is both the similarities and the differences in the way 

their programs are addressing that goal, 

Six Residential IYograms 

Residential Program #1 

Structure: This 60-day program was established in 1994. Located in a large city in 

Oklahoma, it is run by a small chemical dependence agency under a subcontract with 

a major hospital, Prior to establishing this program, the hospital led the formation of 

a consortium of agencies providing a continuum of services including detox, inpatient, 

residential and aftercare programs. 

4

Training andevaluation are both keycomponents ofthis program. Training is 

provided not only for staff in the program itself, but for residents and medical students 

at the university’s College of Medicine. Evaluation will be conducted every quarter, 

Funding Funding is provided by mental health and substance abuse block grant 

funds. 

Clients: The program has 16 beds, with an average census of 14 clients. The majority 

of the 26 clients (half male, half female, 35-40 years old ) served in the first quarter of 

operation experienced depression, with a high occurrence of personality disorders. 

They abuse alcohol, marijuana, or crack cocaine, and polyabuse is not uncommon. 

Services: Intake, assessment, and referral to this program are done at the hospital by 

a’treatment team comprised of the program director, a psychiatrist, an intensive case 

manager from the residential program, and a mental illness specialist. The team 

reviews each case weekly and psychotropic medications are provided through the 

hospital, with oversight by the psychiatrist. 

The residential program itself provides case management, individual and group 

counseling, and education groups.3 The agency has a very diversified array of 

chemical dependency services available to the clients as well. Staff consist of the case 

manager, clinicians, and counselors. 

Residential Proaam #2 

Structure: This mental health agency, located in a large city in the East, has operated 

two programs for persons with co-occurring MH/SA disorders for a year and a half -

an 18 month residential program and a continuous treatment team (CTT) which 

deliberately targets people who have failed in another agency CIT. One person 

supervises both programs and also carries several clients in a case management 

capacity. Each program has a staff of seven including a clinical supervisor, nurse, and 

a diverse group of people conducting case management and the other activities of the 

program. 

Funding Funding includes State funds and Federal funds from a special grant. The 

agency director has done some formal outcome evaluation of clients with co-occurring 

MH/SA disorders and would like to continue, but said that a cut in their Federal grant 

has precluded continuing formal evaluation at the moment. 

Clients: Federal funding mandates targeting people of color, women of childbearing 

age, and people at risk for HIV infection. There are 15 beds in the program, and 25 

3 Wesoon learnedthatrespondentstalkingabout ‘>~choeducation” were referringto diff?rentthing from C1OS.WSto counseling 

sessio~ and from teaching rux only about mental illness but abo about mbstance abuse and other topics such as daiiy living skills 

Hencewe have chosento use the broader term “education”in this report 

5 
clients come throughout in a year, Two-thirds are men. Clients are severely mentally 

i114;some also have borderline personality disorders. 

Semkes: The agency provides access to a continuum of services, beginning with case 

management, through the continuous treatment team, to which residential clients can 

“graduate” and remain as long as needed. Within the residential program, clients 

receive medications and psychiatric monitoring along with individual and group 

counseling, and education. They are required to attend 12-step5 meetings, including 

some Double Troubleb meetings, daily, They also participate in recreational activities, 

which the agency views as important replacements for substance use/abuse. 

Residential Program #3 

Structure: This is a 90-day residential program run by a private non-profit (religious 

based) social service agency in Alaska. The agency is substance-abuse based and this 

program is strongly grounded in the 12-step philosophy. It is staffed by the director, 

two alcohol and drug counselors, and four paraprofessional mental health aides. 

Funding Funding includes Salvation Army funds and special Federal funds 

specifically targeted at Alaska Natives. 

Clients: Half or more of the clients are Alaskan Natives. Two thirds are male, and 

on average, clients are in their mid-20s. Clients have chronic mental illnesses and 

some from post traumatic stress disorder due to prior abuse in the family. They abuse 

alcohol, marijuana, and crack cocaine. 

Semites: Clients with chronic mental illness receive mental health-related services at 

the local CMHC. A psychiatrist comes to the program weekly to monitor medications 

for the Alaska Native clients, specifically. The director reports that the agency 

recently “lost” a halfway house and case manager for an aftercare program. She also 

said that clients with personality or mood disorders who are not connected with either 

the CMHC or the Indian Health Service health care network often relapse during 

lengthy waits for services from those systems, 

The residential program runs 12-step study groups, educational groups, and some 

recreational activities. Some clients also attend 12-step groups in the community. The 

program refers a small percentage of clients to the vocational rehabilitation agency in 

the community at the end of their stay. 

4 The severe or chronic mental illnesses named wereprimarily schizophrenia and depression. 

5 Al~o&li~s Anonymo~ Narcoh’csAnonymous, etc. 

6A WI of 12-stepprogram developed specificallyfor persons with dual disorders. 

6 
Residential Promam #4 

Structure: ~isisa23-year-old substance abuse provider, which has been seting the 

persons with co-occurring MH/SA disorders in this Nebraska city for some 5 years. 

Staff consists of a clinical director, a psychiatrist consultant, counselors, nurses, and full 

and part-time recreation therapists. In addition to this residential program, the agency 

runs an outpatient program and a residential program for adolescents with cooccurring MH/SA disorders. 

Funding Federal CSAT-CMHS demonstration funds, State, city and county funds, 

and some United Way dollars, provide funding, with a small amount of Medicaid and 

private reimbursement. 

Clients: Clients are homeless or at risk of hopelessness. The program houses 30 

adults and 15 youths at a time. Roughly two-thirds are male. Clients are chronically 

mentally ill; some have personality disorders. Reportedly, a majority have been 

victims of sexual abuse. Substances used are alcohol and cocaine, including crack. 

Reportedly some younger clients use LSD or inhalants. Some adults abuse 

amphetamines. 

Services: This program was described as a modified therapeutic community with a 

long-term approach. Clients may remain for up to 1 year. Case managers at the 

parent agency link clients with services needed outside the agency. Residential 

services include medication management, group and individual counseling, education, 

and recreational activities. These latter are a large part of the program; staff believe 

strongly that clients must learn to use leisure time in a healthy way to replace 

drug/alcohol use. 

Residential Prom-am #5 

Structure: This 2-year-old program located in a large city in California is run by a 

private non-profit agency serving veterans. 

Fundhqy CSAT-CMHS demonstration funds, Health Care for the Homeless, HUD, 

and the Department of Labor were all mentioned as sources of funding. 

Clients: The 80 clients are 85 percent male and average around 45 years old. All are 

veterans who have been homeless or are at risk of hopelessness. They have chronic 

mental illnesses; respondents especially see depression, anxiety, and post traumatic 

stress disorder. Most clients are judged to be employable. 

Services Each client is assigned a case manager and a counselor. Respondents 

described the program as a structured program built on a social model, with a heavy 

focus on peer support, jobs, self-sufficiency, and integration into the community. The 
emphasis is on building confidence, self esteem, a sense of community, and, especially, 

a sober lifestyle. 

Clients receive medications through Veterans Administration programs. In-house 

activities include case management, counseling (group and individual), and a variety of 

education groups. Clients are required to attend 12-step meetings either on or off-site 

and may continue to attend them after graduating from the program. 

Residential Promam #6 

Structure: This is a large private non-profit human service agency in New York City. 

It runs both housing programs and a day treatment program for people with cooccurring MH/SA disorders. The housing program is about 3 years old. 

Funding The program is funded by CSAT-CMHS demonstration funds; Medicaid and 

Medicare reimbursement were also mentioned. 

Clients: Three hundred of the 400 served by this program have co-occurring MH/SA 

disorders. From 60 percent to 80 percent are male and they range in age from 30 to 

50 years old, although most are in their 30s. Clients are chronically mentally ill; some 

have personality disorders. They use primarily alcohol and crack cocaine. Clients are 

homeless or at risk of hopelessness. 

Semites: The housing program is tailored to individual needs and geared to provide 

the least restrictive living environment possible for clients, for as long as they need it. 

It includes a range of housing from independent living to housing with intensive 

support services, where residence counselors working in teams make frequent visits to 

clients. Clients can participate in the agency’s day treatment program for persons with 

co-occurring MH/SA disorders and, through its case managers, access other services 

both in and outside the agency. Most clients have a psychiatrist or are affiliated with a 

hospital or clinic for on-going mental health care. 

Eight Outpatient l?ogram.r 

Outpatient ProEram #1 

Structure This 5-year-old partial day treatment program is run by a large private 

non-profit social service agency in New York City. The program operates from 4 to 8 

pm Monday through Thursday (after-school hours). Clients may remain in the 

program up to 18 months. Staff include three social workers, a part-time drug and 

alcohol counselor, and a part-time psychiatrist consultant. There is a low client to 

staff ratio. 

Because so many of their clients have learning disabilities, the agency is now 

developing an alternative high school. 

8

Funding: Theprogram wasstarted with funding from aspecialtask force tith the 

mission of bridging the gap between the mental health and substance abuse needs of 

adolescents. 

Clients: The program serves adolescents from 13 to 18 years old. Some 14 clients


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


They experience a wide range of emotional disturbances, especially emergent


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


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


percent of the girls have been sexually abused.


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


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


program that provides close monitoring of psychotropic medications, routine drug


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


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


to complete a thorough assessment of each client.


Outpatient Program #2


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


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


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


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


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


providers.


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


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


program. Respondents reported that Medicare and Medicaid requirements that


substance abuse counselors have Master’s degrees restrict the program’s ability to hire


Native Americans, since few Native Americans have these degrees.


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


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


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


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


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


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


housing.


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


individual therapy, medication management, and family counseling. The program’s


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


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


9

meets on the reservation. The agency coordinates its services with those of the Indian 

Health Service wherever possible. 

Out~atient Promam #3 

Structure: Asubstance abuse agency ina Virginia ci~developed this program 4 years 

ago, The program runs Monday through Friday, three hours a day, and lasts from 12 

to 18 months depending on client. The program is expanding and its two therapists 

will soon become full-time. 

Funding County substance abuse dollars fund the program. 

Clients: The program serves a maximum of 12 clients, most from 30 to 35 years old. 

In addition to chronic mental illness, many clients reportedly also have personality 

disorders. Some have experienced childhood abuse. Many of the women in the 

program are mothers. Clients abuse alcohol and crack. Some clients are homeless, 

but many live with their parents. All receive SS1 or SSDI and Medicaid. 

Services: Therapists carry six clients each, and provide education and individual and 

group therapy in addition to case management. Each client also has a prima~ 

counselor at other agencies in the mental health system. Although the primary focus 

of this program is on substance abuse, the goal is to help clients understand both their 

mental illnesses and their addictions as well as to give them the skills and support 

necessary to maintain abstinence. 

Outpatient Prowam #4 

Structure: This 3-year-old program in Texas is based in a mental health agency and 

targets homeless people with co-occurring MH/SA disorders. The agency takes a 

comprehensive approach, via case management, to meeting many client needs in the 

hope that they will become more independent and live in the community. The 

agency’s homeless services unit first identifies homeless people with co-occurring 

MH/SA disorders. Case managers in this program then link those clients with services 

within and outside the agency for 6 months to a year. After leaving this program, 

clients continue with another case manager from the main program of the agency. 

Staff consists of one administrator/case manager, and a case manager. Each carries 15 

to 20 clients. Under a contract, a psychiatrist visits the program twice a month. 

Funding Funding comes from Federal PATH dollars as well as funding from the 

parent agency. Reportedly, the agency cannot bill for Medicaid reimbursement due to 

its Federal grant. 

Clients: The program sexves 30 to 35 clients at a time (about 350 a year). Most 

clients are in their mid-20s to mid-40s. The PATH grant requires that all of the 

program’s clients be homeless and chronically mentally ill. Reportedly, the agency is 

10 
seeing a rapid increase in clients who have organic disorders due to either heavy


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


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


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


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


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


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


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


where possible.


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


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


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


other programs, however.


Outpatient Promam #5


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


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


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


term support.


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


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


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


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


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


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


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


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


abuse.


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


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


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


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


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


Outpatient Promam #6


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


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


community agencies focused on co-occurring MH/SA disorders was set up by the 

agency several years ago, and the agency holds an annual conference on co-occurring 

11 
MH/SAdisorders (some 150people attended themost recent one). Italsoholdsa9-

week training seminar and is developing a resource manual for staff. The program 

director is a psychiatrist with several years of experience in this field, who is also on 

the faculty of a major university. Services are divided into two components, one for 

persons with chronic mental illnesses and another for persons with less severe mental 

illnesses. 

Funding This program receives Federal funding from the National Institute on Drug 

Abuse. The parent agency funds both mental health services and a substance abuse 

program. 

Clients: Clients, who have chronic mental illnesses, are reportedly mostly in their 20s 

and 30s. About 40 percent are female, and 50 percent are minority. They have 

histories of poor compliance with medications, frequent rehospitalizations, legal 

problems, and homelessness; a very high percentage reportedly have learning 

disabilities. All receive SS1 and Medicaid. 

Services: The agency offers a full continuum of care including community treatment 

teams that provide case management and referral, inpatient, outpatient, day 

hospitalization, and relapse prevention services. The director described the program’s 

approach to this population as eclectic, integrating a wide variety of services into a 

network, with individual clients referred to services according to their needs. Those 

with chronic mental illnesses receive services within the provider agency. Those with 

less severe mental illnesses receive concurrent semices from this provider and a 

substance abuse provider. 

Besides the director, staff include an administrator who has some clinical duties and 

oversees research, and three people who share a full-time position and provide 

consultation and training to other staff at both the mental health and substance abuse 

agencies. More staff will be hired to carry out the research component, which is to 

continue for several years. 

Outpatient ProQram #7 

Structure: This program has been run by a county CMHC in Illinois for 3 years. It 

offers intensive case management on an outpatient basis. Staff include a coordinator, 

two case managers, and a part-time psychiatrist. Staff know and work with each 

others’ clients. They take a longitudinal view of treatment and care, and expect clients 

to use the sexvice throughout their lives. 

Funding The program is part of a special Statewide program for people with cooccurring MH/SA disorders. Funding comes from the State mental health and 

substance abuse agencies, and Medicaid reimbursement. 

Clients: The program serves 40 clients. Their average age is 32 and 75 percent are 

male. The program sees clients with schizophrenia, primarily, and many reportedly 

12 
also have personality disorders. Alcohol use is primary; clients also use marijuana and 

respondents said that crack cocaine “is like a plague.” Many clients have continual 

housing problems. They reportedly have “burned down all their clinical bridges” 

before coming to this program. About 70 percent receive SS1 and Medicaid. There is 

a waiting list of 30 clients. 

Semites: The program uses case management to link clients with community services. 

Case managers each carry 15 clients; the coordinator has a caseload of 10. Staff also 

do some group work such as modified 12-step groups using an educational, nonconfrontational approach, or education groups. 

Outpatient Program #8 

Structure: This 2-year-old program in California was developed from a homeless 

program for chronically mentally ill clients. It is this city’s only program for clients 

with co-occurring MH/SA disorders. Treatment lasts for 16 weeks, although the time 

limit is flexible. Staff include the coordinator (who serves part-time as a case 

manager), case managers, a part-time psychiatrist, and a full-time therapist position “L.. --Ala! 1-.. L.. - :--l:..: A.. -l. Mltu Uy Lwu Mlulvluutlls. 

Funding: Funding includes Medicaid reimbursement and CSAT-CMHS demonstration 

dollars. 

Clients: The 108 clients have severe mental illnesses. Average age is the early 30s. 

Some reportedly have borderline personalities, especially fem~les~ Many use ~lcohol 

to self-medicate; they also use cocaine, PCP, and crack. Many clients have been 

homeless. All receive SS1 and Medicaid. 

Services: Intensive case management is the agency’s core service. Other program 

components include medication management, groups that address daily living skills, 

mental health and substance abuse education, and a Double Trouble 12-step group. 

Ten Day l’keatmentlPamal Hospitaluation Bograms 

Dav Treatment/Partial Hospitalization Promam #1 

Structure: Run by a CMHC in Ohio, this program was established in 1988. It 

operates 5 days a week, 4 or 5 hours a day. It was established when the county 

mental health board identified a need for services for people with severe mental 

illness and substance abuse problems. Most clients remain in the program for 6 to 9 

months, although they may stay indefinitely. Staff include a psychiatrist, case 

managers with caseloads of 15, counselors, a nurse, and an art therapist. 

Funding The county mental health board is the primary funder. The program bills 

Medicaid and Medicare for some services as a partial hospitalization program. United 

Way also provides some funding, 

13

Clients: The program has some 50 active clients, predominantly African American 

men with schizophrenia/schizo-affective disorders. The average age is 32. Clients are 

polyusers. The most popular drugs are crack cocaine (58 percent), alcohol (35 

percent), and marijuana (4 percent). In addition, 50 percent of clients may be on 

parole at any one time. 

Services: Services include intensive case management with referral to services as 

needed, medication management, group and individual counseling, education, 

recreation therapy to counter boredom and teach clients socialization skills, and 12-

step groups, both traditional and modified. Case managers sometimes accompany 

clients to 12-step groups in the community to help them feel more comfortable with 

participating. 

Dav Treatment/Partial Hospitalization Promam #2 

Structure: This program in Texas is only a few months old. It is run by the county 

comprehensive CMHC and operates 5 days a week from 8 am. to 5 pm. It is 90 days 

in duration, with some flexibility for a client to extend. The agency runs a residential 

program for clients with co-occurring MH/SA disorders which led to the formation of 

this day program. Staff include a director who also serves as a caseworker and 

counselor, a psychiatrist, and a licensed vocational nurse. 

Funding The program receives county mental health dollars and Medicaid 

reimbursement. 

Clients: The program serves 20 severely mentally ill clients, 60 percent of them male 

and most in their 20s and 30s. Some 30 percent receive SS1 and Medicaid. About 25 

percent are referred to the program on probation. Many have histories of physical or 

sexual abuse (reportedly up to 90 percent of females and 50 percent of males), or 

come from families where substance abuse is present. 

Services: The agency provides a continuum of services from outreach to treatment to 

aftercare, allowing clients to move back and forth between programs as needed. This 

program focuses on education and peer support, mostly within groups, to encourage 

sobriety and increase client stability. It provides medication management, education, 

12-step groups in the community, and modified 12-step discussion groups in house. 

Dav Treatment/Partial Hospitalization Program #3 

Structure: This 6-year-old program is in upstate New York. According to the 

director, the program is “approaching maturity.” It is run by the mental health 

department of a hospital and operates 5 days a week for 5 hours. Clients stay an 

average of 18 to 36 months. Staff include primary care counselors, who oversee 

treatment, a vocational rehabilitation counselor, and a recreation counselor, 

14

Funding Though begun initially with Federal grant monies, the program now is 

funded primarily through Medicaid reimbursement. 

Clients: The program’s mission is to seine persons with severe mental illnesses who 

have failed in other treatment programs. Their clients include persons with anxiety 

and personality disorders in addition to schizophrenia and depression. Sixty percent of 

the 50 clients are male, most in their mid-20s to mid-30s. Twenty percent are African 

American. Almost all clients receive SS1 and Medicaid. Many clients have been or 

are at risk of being homeless, and 20 to 30 percent are on parole. Reportedly, clients 

are at all levels of functioning. 

Services: The program provides medication monitoring, individual therapy, vocational 

counseling, group counseling and education. Clients attend the groups most in 

keeping with their individual needs; some 20-25 groups are offered every 4 month 

cycle. Some clients also attend 12-step meetings in the community. Through case 

management, access to other services is provided. 

Dav Treatment/Partial Hos~italization Pro~ram #4 

Structure: This 4-year-old program in Indiana was established by a CMHC. It is 

housed in the same building as a homeless shelter. The program operates Monday 

through Friday, 6 hours a day. Up to 40 treatment days per client are covered under 

State Medicaid guidelines. The program is staffed by a director and two counselors. 

Funding Half of the funding is from the State substance abuse agency and half from 

Medicaid or Medicare. 

Clients: The program serves both clients with co-occurring MH/SA disorders and 

others with problems only with substance abuse. Clients average between 30 and 40 

years old. Twenty percent are homeless persons living at the shelter; other clients 

include court-order indigents and clients referred by the CMHC. Between 80 to 90 

percent of the clients are male; another program in the city serves women. Besides 

having a wide variety of problems related to mental illness or substance abuse, clients 

are also very mixed in terms of levels of functioning. 

Sexvices: This is a group-oriented, 12-step-based program (specifically focused on 

steps 1-3.) Attendance at sessions is mandatory. Groups include 12-step study 

sessions, education, daily Alcoholics Anonymous meetings, group therapy, and 

community meetings. Medication needs are met by the CMHC. 

Dav Treatment/Partial Hospitalization ProEram #5 

Structure: This 4-year-old program is located in a suburb of a major metropolitan 

area in the South, It operates Monday through Friday, 6 hours a day. There is a 90 

day time limit, recently imposed due to a flood of new clients (see Clients below). 

15

FundirIg Funding is primarily Medicaid reimbursement, but also includes some


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


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


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


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


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


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


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


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


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


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


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


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


very high turnover rate.


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


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


learn, and make some visible effort to adhere to the program’s schedule and demands.


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


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


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


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


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


Dav Treatment/Partial Hospitalization Pro~ram #6


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


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


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


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


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


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


to 2 years, then enter Section 8 housing and continue in the agency’s case


management program.


Funding Funding is primarily Medicaid reimbursement, with some private


contributions. The agency’s housing program receives funding from HUD; the


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


homeless).


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


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


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


16

third have a prison record, a third are developmentally disabled, and many were raised 

in dysfunctional families, or in a foster home or institution. 

Services: Services include case management, medication management, counseling, 

education, a special Alcoholics Anonymous for homeless people (clients also go to 

community AA meetings), and recreational activities, including 1 week a year spent at 

a church camp rented by the agency. Recreational activities include ballroom dancing, 

a talent show, and a “Hopes Course” designed to build self esteem. A strong emphasis 

on permanency, a foreign concept to most homeless people, underlies the program. 

The program has 25 rules which the clients vote on and then police themselves; the 

director believes that structure, with consequences for violating rules, is important. 

Dav Treatment/Partial Hospitalization Program #7 

Structure: This 2-year-old day treatment program in Oregon is run by a mental health 

provider. The program is part of a comprehensive array of services offered by the


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


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


and a half time occupational therapist.


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


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


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


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


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


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


or both.


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


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


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


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


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


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


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


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


Dav Treatment/Partial Hospitalization Prom-am #8 

Structure: This agency is located in a medium sized city in Ohio. In addition to this 

6-year-old partial hospitalization program, the agency also runs a small residential 

program and an outpatient program. Partial hospitalization is highly structured and 

runs 5 days a week, 3 hours a day. Treatment is conducted in 12 week modules, 

although clients’ time in treatment is not limited. 

17

Funding Theprogram is funded through coun~tw dollars, State mental health


dollars (through thecounty), andsome Federal grants. Theprogram’s funding is tied


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


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


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


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


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


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


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


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


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


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


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


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


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


Dav Treatment/Partial Hospitalization Pro~ram #9


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


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


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


program’s 3 levels, although deadlines are flexible. Staff include a psychiatrist, a case


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


groups.


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


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


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


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


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


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


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


clients by the end of 1994.


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


environment which respondents described as “friendly” and “emotional.” There are


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


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


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


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


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


18

Dav Treatment/Partial Hospitalization Promam #10 

Structure: This not-for-profit multi-service agency in New York City was founded 25 

years ago to help homeless substance abusers and has since added mental health care 

to its services. The program for clients with co-occurring MH/SA disorders was 

established in 1986. The agency offers a continuum of care that includes housing 

programs and a day treatment program for people with co-occurring MH/SA 

disorders. Clients can take advantage of both programs at once and stay with the 

agency indefinitely. (See also Residential Programs) 

The day treatment program runs Monday through Friday, 9:00 am to 2:30 pm. It 

emphasizes activity and participation, and case managers ensure that program 

attendance is high. A multi-disciplinary team of primary therapists, case managers, a 

part-time psychiatrist, and part-time art and music therapists, provides care. Client 

input on program is encouraged through one-on-one meetings between elected 

consumer representatives and the program director. 

Funding The program receives funds from the CSAT-CMHS demonstration program, 

and Medicaid and Medicare reimbursement. 

Clients The program serves 36 clients at a time, with a total of 50 a year. Currently, 

85 percent of the clients are male, 80 percent are minority, and average age is 

between 30 and 40 years old. All receive SS1 or SSDI or VA benefits as well as 

Medicaid. In addition to severe mental illnesses, some clients are infected with the 

HIV/AIDS virus, many have experienced physical abuse, been homeless, or served 

time in jail. 

Sewkxs Services include medication management, individual therapy, group therapy, 

modified 12-step groups which meet in house, education, music and art therapy, field 

trips, and physical exercise. Art therapy is said to have been especially successful. 

Average daily attendance is reportedly over 90 percent. 

Five Continuous Treatment Team Programs 

Continuous Treatment Team Prom-am #1 

Structure: This is a pilot demonstration program begun in 1990 which is part of a 

previously existing program for persons with severe mental illnesses only. Located in 

Wisconsin, the program constitutes an outpatient department of the State mental 

hospital located there. Based on a medical model, the program uses a continuous 

treatment team with staff from many disciplines, supervised by psychiatrists. The 

program’s goal is to offer whatever assistance is needed by individual clients to 

improve their functioning in the larger community. Clients are expected to remain 

with the program for life. 

19

Funding State hospital funding, private insurance, and Medicaid are sources of 

funding. The State has a special Medicaid reimbursement category called “community 

support services” which allows billing for services related to both mental health and 

substance abuse. 

Clients: The 75 clients with co-occurring MH/SA disorders constitute about 60 

percent of all clients in this program (the others have mental illnesses only). They are 

90 percent male. To enter the program, clients must have spent less than a 1 year in 

the State hospital, be between 18 and 30 years old, and have a chronic mental illness 

(Axis I disorder). Drugs used and abused include alcohol, marijuana, cocaine, and 

over-the-counter stimulants. 

One third of the clients are described by the director as “moving targets” whose 

substance abuse pre-dated their mental illness and is very entrenched. They have 

failed in every other treatment program and are very difficult to engage. 

Services: The program takes a highly individualized approach to clients. It has a 

strong emphasis on setting limits and also relies heavily on work as a treatment 

modality, finding that many clients use substances just to counteract boredom and 

have something to do; the program has a 50 to 60 percent job placement rate. The 

program also serves as representative payee for its clients. 

Several members of the team work with each client simultaneously and 

interchangeably, giving clients several people to rely on and allowing staff to share 

responsibility for clients. Staff also work with important people in their clients’ lives. 

Continuous Treatment Team #2 

Structure: This program, located in a rural two-county area in Wisconsin, is run by a 

mental health provider. It takes a long-term view of treatment, expecting to carry 

clients for the rest of their lives. Staff consists of a psychiatrist, a clinical coordinator, 

and case managers with 14 clients each, who serve clients in the home as well as 

referring them to services outside. 

Funding The program receives Medicaid reimbursement under a special Stateestablished category called “community support services,” which allows billing for 

services related to both mental health and substance abuse. 

Clients: Two-thirds of the program’s 51 clients are male. They range in age from 22 

to 53. In addition to major Axis I mental illnesses (a program requirement), many 

clients, especially younger ones, reportedly have post traumatic stress disorder due to 

severe childhood abuse. They are using or abusing alcohol, marijuana, and over-thecounter and prescription medications. Almost all clients are on some form of public 

assistance. 

20

Services: Theagency integrated substance abuse treatment into its mental health 

treatment, realizing that most clients were going to need long-term substance abuse 

treatment combined with a great deal of support and interventions in many arenas. 

The program tries to provide clients with structure and looks for replacement 

behaviors for substance abuse. 

Services include case management, medication management, psychiatric treatment, 

psychosocial rehabilitation, and vocational support (finding jobs and supporting those 

who work - about 25 percent of their clients). Some clients receive help in the home 

with things such as money management, hygiene, or buying and preparing food, 

through ancillary services purchased from another program. Respondents described 

the program’s approach as being individualized and “whole health,” meaning that they 

try to meet many different client needs. 

Continuous Treatment Team #3 

Structure This continuous treatment team is one of two programs (the other is a 

residential program) specifically for persons with co-occurring MH/SA disorders. 

Teams of case managers, nurses, clinicians, associate and assistant clinicians work with 

clients to provide whatever services they need. Clients may graduate from the 

residential program to this program, where they may stay indefinitely. 

Funding The agency is in the second year of a 3 year Federal grant from the Center 

for Substance Abuse Treatment to serve persons of color, pregnant women, and 

people with HIV. A recent cut in the grant reportedly led the agency to eliminate its 

program evaluation effort. 

Clients: The program serves about 70 clients, 80 percent of them male, They have 

schizophrenia or major depression, and some have personality disorders. They most 

commonly abuse alcohol or crack cocaine; use of heroin is reportedly on the rise and 

polyabuse is also common. Many clients are HIV positive, and all are people of color. 

Histories of hopelessness or brushes with the criminal justice system are common. 

Almost all clients receive SS1, Medicaid, or both. 

Services: The goal of staff is to help clients lead as normal a life as possible by 

providing whatever help they need, from the most basic life skills to education, 

vocational education, and jobs. The agency provides medication management, 

counseling, education, 12-step groups (including a Double Trouble group), and a 

“social skills” (recreation) group described by staff as very therapeutic. Clients are 

referred out to other agencies for services not provided by this program. 

Continuous Treatment Team #4 

Structure: This program operates community treatment teams of 5 to 7 staff, 

including supervisors, case managers, and specialists (vocational, rehabilitation, 

substance abuse). Located in Missouri, the program was started 2 years ago when its 

21 
parent mental health center found that referring their homeless clients with co­


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


clients resisted going and continued using.


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


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


illnesses.


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


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


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


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


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


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


The majority receive SS1, Medicaid, or both.


Semites: Teams reportedly take a “generalist” approach in providing supportive


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


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


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


each client.


Continuous Treatment Team #5


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


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


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


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


managers, and clinicians.


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


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


source.


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


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


The majority receive SS1 or SSDI.


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


Dartmouth University to provide “integrative, comprehensive, concurrent, sequential


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


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


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


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


22

One Other Program 

Structure: Wespoke totheday manager inasingle room occupancy hotel (SRO) ina 

Vermont. Theposition wasestablished 2yearsago following arashof false fire 

alarms, and subsequent warnings by the city to the entity running the SRO. The 

manager works 6 hours a day, 5 days a week. 

Funding The SRO receives funding from HUD (moderate rehabilitation) and the 

State, and will soon receive HUD Shelter Plus Care dollars. The manager’s position is 

funded by the local CMHC. 

Clients: At least half of the SRO’S 25 residents have co-occurring MH/SA disorders. 

The majority are men, about 40 years old, who have serious mental illnesses, drink 

mainly beer, are very isolated socially, and have lived at the SRO for years. They are 

clients of the CMHC. A smaller number of residents are young men, referred by the 

State hospital or a local homeless program, who are heavy drinkers. Reportedly 

resistent to treatment, they tend to have a social support network of some kind still 

intact, and almost always leave the SRO within a few weeks or months. 

Sexvices: No treatment-related services are offered in the SRO. Residents who are 

severely mentally ill are clients of the CMHC and receive case management and other 

services there. The manager views her main goal as trying to overcome clients’ 

isolation through an “open door policy,” trying to make a personal connection and 

draw residents into contact with her and with each other. However she is very 

disappointed by the lack of in-house services and activities, from treatment to 

recreation and socialization, which she believes residents desperately need. 

23