Addressing Co-Occurring

Disorders in Non-Traditional

Service Settings

OVERVIEW PAPER 4
Acknowledgments

COCE Overview Papers are produced by The CDM Group, Inc.

(CDM) under Co-Occurring Center for Excellence (COCE) Contract

Number 270-2003-00004, Task Order Number 270-2003-00004-

0001 with the Substance Abuse and Mental Health Services

Administration (SAMHSA), U.S. Department of Health and Human

Services (DHHS). Jorielle R. Brown, Ph.D., Center for Substance

Abuse Treatment (CSAT), serves as COCE’s Task Order Officer, and

Lawrence Rickards, Ph.D., Center for Mental Health Services

(CMHS), serves as the Alternate Task Order Officer. George Kanuck,

COCE’s Task Order Officer with CSAT from September 2003

through November 2005, provided the initial Federal guidance

and support for these products.

COCE Overview Papers follow a rigorous development process,

including peer review. They incorporate contributions from COCE

Senior Staff, Senior Fellows, consultants, and the CDM production

team. Senior Staff members Michael D. Klitzner, Ph.D., Fred C.

Osher, M.D., and Rose M. Urban, M.S.W., J.D., LCSW, LCAS, co-led

the content and development process. Senior Staff member Fred

C. Osher, M.D., made major writing contributions. Other major

contributions were made by Project Director Jill G. Hensley, M.A.;

Senior Staff Members Stanley Sacks, Ph.D., and Sheldon R.

Weinberg, Ph.D.; and Senior Fellows Michael Kirby, Ph.D., Douglas

M. Ziedonis, M.D., Ph.D., and Joan E. Zweben, Ph.D. Editorial

support was provided by CDM staff members Jason Merritt, Janet

Humphrey, Michelle Myers, and Darlene Colbert.

Disclaimer

The contents of this overview paper do not necessarily reflect the

views or policies of CSAT, CMHS, SAMHSA, or DHHS. The

guidelines in this paper should not be considered substitutes for

individualized client care and treatment decisions.

Public Domain Notice

All materials appearing in COCE Overview Papers, except those

taken directly from copyrighted sources, are in the public

domain and may be reproduced or copied without permission

from SAMHSA/CSAT/CMHS or the authors.

About COCE and COCE Overview Papers

The Co-Occurring Center for Excellence (COCE), funded through the Substance Abuse and Mental Health Services

Administration (SAMHSA), is a leading national resource for the field of co-occurring mental health and substance

use disorders (COD). COCE’s mission is threefold: (1) to receive and transmit advances in treatment for all levels of

COD severity, (2) to guide enhancements in the infrastructure and clinical capacities of service systems, and (3) to

foster the infusion and adoption of evidence- and consensus-based COD treatment and program innovations into

clinical practice. COCE consists of national and regional experts including COCE Senior Staff, Senior Fellows,

Steering Council, affiliated organizations (see inside back cover), and a network of more than 200 senior

consultants, all of whom join service recipients in shaping COCE’s mission, guiding principles, and approaches.

COCE accomplishes its mission through technical assistance and training delivered through curriculums and

materials on-line, by telephone, and through in-person consultation.

COCE Overview Papers are concise and easy-to-read introductions to state-of-the-art knowledge in COD. They are

anchored in current science, research, and practices. The intended audiences for these overview papers are mental

health and substance abuse administrators and policymakers at State and local levels, their counterparts in

American Indian tribes, clinical providers, other providers, and agencies and systems through which clients might

enter the COD treatment system. For a complete list of available overview papers, see the back cover.

For more information on COCE, including eligibility requirements and processes for receiving training or technical

assistance, direct your e-mail to coce@samhsa.hhs.gov, call (301) 951-3369, or visit COCE’s Web site at

www.coce.samhsa.gov.

Electronic Access and Copies of Publication

Copies may be obtained free of charge from SAMHSA’s National

Clearinghouse for Alcohol and Drug Information (NCADI),

(800) 729-6686; TDD (for hearing impaired), (800) 487-4889;

or electronically through the following Internet World Wide

Web sites: www.nacadi.samhsa.gov or www.coce.samhsa.gov.

Recommended Citation

Center for Substance Abuse Treatment. Addressing CoOccurring Disorders in Non-Traditional Service Settings. COCE

Overview Paper 4. DHHS Publication No. (SMA) 07-4277.

Rockville, MD: Substance Abuse and Mental Health Services

Administration, and Center for Mental Health Services, 2007.

Originating Offices

Co-Occurring and Homeless Activities Branch, Division of State

and Community Assistance, Center for Substance Abuse

Treatment, Substance Abuse and Mental Health Services

Administration, 1 Choke Cherry Road, Rockville, MD 20857.

Homeless Programs Branch, Division of Service and Systems

Improvement, Center for Mental Health Services, Substance

Abuse and Mental Health Services Administration, 1 Choke

Cherry Road, Rockville, MD 20857.

Publication History

COCE Overview Papers are revised as the need arises. For a

summary of all changes made in each version, go to COCE’s

Web site at coce.samhsa.gov/cod_resources/papers.htm. Printed

copies of this paper may not be as current as the version posted

on the Web site.

DHHS Publication No. (SMA) 07-4277

Printed 2007.
Addressing Co-Occurring Disorders in Non-Traditional Service Settings 1

SUMMARY

Only about half the people with co-occurring disorders (COD) receive any services within substance abuse and mental health

(SA/MH) settings. Settings outside the SA/MH system, or settings where service missions do not include a primary focus on

COD, are the focus of this overview paper. Primary health, public safety and criminal justice, and social service settings,

where persons with COD are likely to be seen, are highlighted. These settings should be prepared to identify and effectively

respond to persons with COD. The use of specialized techniques appropriate to these settings can increase the likelihood that

the person with COD will access treatment.

INTRODUCTION

Persons with COD reside throughout our communities and

move through all system and service locales. While significant progress is being made within SA/MH settings to

comprehensively address the complex needs of persons with

COD in an integrated manner, more than half of all persons

with COD do not access any SA/MH services (Office of

Applied Studies, 2006). Unrecognized and untreated COD

results in excess morbidity and mortality; unnecessary health

and personal expenditures; and frustration for families,

intimates, and service providers. However, the disabilities and

social consequences associated with COD bring those

affected in contact with a number of public health, public

safety, and social welfare providers. These contacts, if

handled with sensitivity to COD issues, afford unique

opportunities for identification, initial engagement, and

linkage to appropriate care systems.

LITERATURE HIGHLIGHTS

SA/MH settings have made significant progress in addressing

the needs of persons with COD. However, many persons with

COD never see a SA/MH provider. The 2005 National Survey

on Drug Use and Health shows that 53 percent of persons

with serious psychological distress (SPD) and a co-occurring

substance use disorder received no treatment in the 12

months preceding the survey (Office of Applied Studies,

2006). Although large numbers of persons with COD are not

seen in SA/MH settings, they can be found in several other

settings:

• About 70 percent of the U.S. population sees a primary care

physician every two years (Fleming et al., 1997). Because of

the high frequency of medical conditions that co-occur with

COD and the stigma associated with SA/MH disorders that

leads those with the disorders to avoid formal treatment,

persons with COD often seek medical care in emergency

rooms and primary care settings (Curran et al., 2003; Druss

et al., 2006).

• There has been considerable growth in the number of

persons having contact with the criminal justice system

over the past decade. More than 14 million “bookings”

occur in U.S. jails each year (Bureau of Justice Statistics,

2005), and more than two million people are incarcerated

in the Nation’s prisons and jails (Harrison & Beck, 2005).

The overrepresentation of persons with mental illnesses and

substance use disorders in criminal justice settings is well

documented (CSAT, 2005b; Teplin, 1994; Teplin et al.,

1996), and almost three-quarters of those in jails with

Table 1: Key Definitions

Substance abuse and/or Agencies, programs, and facilities specifically designed to treat psychiatric and/or

mental health (SA/MH) addictive disorders.

service settings

Non-SA/MH settings Settings outside of the SA/MH system where persons with COD are likely to be

encountered. These can be divided into three categories:

• Health settings, including primary care (e.g., community health clinics, HIV/AIDS

treatment programs, family practice locales) and acute care (e.g., emergency

rooms, intensive care units, trauma centers) settings.

• Public safety and criminal justice settings, including police encounters, courts,

jails, prisons, and community corrections settings.

• Social welfare settings, including income support, entitlement and unemployment offices, homeless shelters (as well as makeshift shelters, parks, and abandoned buildings) and the community (e.g., schools and faith and workplace

settings).
2 Addressing Co-Occurring Disorders in Non-Traditional Service Settings

mental illnesses have co-occurring substance use disorders,

while 15 percent of females with substance use disorders

have co-occurring SPD (National GAINS Center, 2002). A

conservative estimate of the prevalence of serious mental

health problems among the juvenile justice population is

20 percent, with many of those youth having co-occurring substance use disorders (Cocozza & Skowyra, 2000).

• The Urban Institute estimates that 2.3–3.5 million people

experience homelessness each year (Burt & Aron, 2000).

Studies suggest that as many as 37 percent of homeless

women and 32 percent of homeless men had co-occurring Axis I and substance use disorders in 2000, a marked

increase from 1990 figures (North et al., 2001). The

settings in which these persons are found include not only

homeless shelters, but also streets, parks, and abandoned

buildings.

• People with and at risk for COD may also be found in

community settings including workplaces, places of

worship, social welfare agencies, and educational institutions.

The principle of “No Wrong Door,” whereby every point of

entry into the healthcare system is seen as an opportunity

for outreach, education, and connection to needed services, is embraced by mental health and addiction service

systems (CSAT, 2000a). This principle can be extended to a

variety of public and private domains such as the non-SA/

MH settings highlighted here. While non-SA/MH settings

should not be expected to provide comprehensive SA/MH

services, they afford important opportunities for identification and engagement of persons with COD and can serve

as gateways to integrated systems of care.

KEY QUESTIONS

1. Why should we be concerned about settings

outside the SA/MH system or settings where

service missions do not include a primary focus on

COD (non-SA/MH settings)?

Only half of persons with COD receive any service within

SA/MH settings. Non-SA/MH settings associated with health

care, public safety, criminal justice, social welfare, work, and

education afford a critical opportunity for identification,

initial engagement, and early intervention. Most persons

with untreated COD cannot function optimally in school, at

work, or within their families and communities. This impaired functioning leads to an overrepresentation in acute

and high-cost health, public safety, criminal justice, and

social welfare settings. The proper identification of SA/MH

disorders that contribute to a person’s social circumstances

or presenting complaint is an important step toward helping

that person realize his or her full potential and live a rewarding life in the community.

2. In what non-SA/MH settings are people with

untreated COD found?

Persons with untreated COD are found everywhere in our

communities. However, the medical, social, and psychological consequences of COD increase the likelihood of their

presence in certain locations. In addition, the severity and

progression of COD can determine the settings in which

untreated persons may initially present, from emergency

rooms to homeless camps.

Figure 1 (page 3) depicts a model that provides a framework

for understanding the range of co-occurring conditions and

the settings in which people with COD are likely to be

found. The model provides guidance to communities in

determining the settings where persons with COD present,

and supports strategies to identify, engage, and respond to

their needs. Descriptions of three categories of non-SA/MH

settings follow.

Health Settings

Primary Care: Well before persons with COD come to the

attention of SA/MH providers, most will have seen a primary

care provider (O’Connor & Schottenfeld, 1998; Simon &

VonKorff, 1995). Depression and anxiety disorders frequently

present as somatic symptoms such as fatigue, headaches,

and pain, which in turn are the leading causes of medical

visits (Kroenke, 2003). Substance use disorders frequently

complicate the management of many chronic illnesses such

as hypertension (Rehm et al., 2003). Conversely, the association of medical problems with mental illnesses and substance

use disorders is also high. In a recent survey of persons with

SPD, 74 percent had at least one diagnosed chronic health

problem (Jones et al., 2004). Moreover, the effects of

substance use on organ systems and the high rates of

infectious disease among persons with substance use

disorders ensure that large numbers of these individuals will

be seen in primary care settings (Saitz, 2003).

Persons with COD tend to be in poorer physical health than

persons without these disorders (Dickey et al., 2002). Within

primary care outpatient settings, it is estimated that 20

percent of patients have a current psychiatric disorder and

20–25 percent have a substance use disorder (Brady, 2002).

As gatekeepers to health services, primary care physicians

have a powerful opportunity to identify COD early and

initiate appropriate treatment—for example, counseling

patients on abstinence (National Center on Addiction and

Substance Abuse, 2000). While they typically do not have

the resources to provide comprehensive care, they can refer

patients to SA/MH specialists.

The United States Preventive Services Task Force recommends

routine screening for alcohol and drug problems and

depression (Agency for Healthcare Research and Quality,

2002, 2004, 2005). These recommendations have not been
Addressing Co-Occurring Disorders in Non-Traditional Service Settings 3

implemented in most primary care settings (Friedmann et al.,

2000; Haack & Alemi, 2002; Woolf et al., 1996). Accordingly, opportunities for early identification and treatment of

COD are being missed but may be better taken advantage of

in the future.

Specialty Care: Specialty care combines primary health care

with specialized services for persons with chronic physical

illnesses, such as HIV/AIDS. The pressing nature of deteriorating physical conditions can motivate a person with COD to

seek care and follow up with suggested treatment plans.

Specialty healthcare settings may have the staff resources to

provide assessment and some treatment services for COD.

Acute Care: Acute care refers to short-term interventions

provided in emergency rooms, trauma centers, and intensive

care units. Untreated COD has a significant impact on

health, and persons with untreated COD will often enter the

service system through contact with urgent or acute care

settings. Screening and identification of SA/MH disorders in

these settings may not be conducted routinely (Kushner et

al., 2001; McClellan & Meyers, 2004; O’Connor &

Schottenfeld, 1998; Simon & VonKorff, 1995). Given the

time constraints, COD treatment beyond brief intervention is

unlikely. However, if COD is suspected through screening

procedures, counseling and referral can be effective in

moving the person to an appropriate treatment setting.

Public Safety and Criminal Justice Settings

Responding to the needs of persons with COD constitutes a

major challenge for police and other public safety officials,

prosecutors, courts, and corrections and supervision systems.

Police: Persons with COD, particularly those without access

to adequate treatment, frequently come in contact with law

enforcement. If illegal or criminal activity is observed, such

as possession or sale of controlled substances, this contact

can begin a series of appearances within criminal justice

settings. Significant police manpower is required to respond

to persons with SA/MH disorders, many of whom are

eventually incarcerated (Reuland, 2004).

Corrections: A considerable number of incarcerated individuals have COD (Abram & Teplin, 1991; Hartwell, 2004;

Steadman et al., 1999). As a consequence of their incarceration, persons with COD have legal rights to have access to

health care, to receive any care that is ordered, and to have

healthcare decisions made by medical personnel (National

Commission on Correctional Health Care, 2003). Unless

COD is recognized and addressed, recidivism is the likely

outcome for incarcerated persons with COD (Hammett et al.,

2001).

Jails may offer the first opportunity for problem identification, treatment, and community referral for those who need

continued treatment (Peters & Matthews, 2001). NonetheFigure 1: Special Settings as a Function of COD Severity

Source: Adapted from National Association of State Mental Health Program Directors (NASMHPD) & National

Association of State Alchool and Drug Abuse Directors (NASADAD), 1999.
4 Addressing Co-Occurring Disorders in Non-Traditional Service Settings

less, jails are high-volume, highly structured, high-turnover

institutions with little time to initiate more than basic

assessment of mental health and substance abuse issues with

appropriately matched urgent care responses. Prisons are

State- or federally operated facilities for inmates with sentences longer than 1 year. As such, they have more opportunities to develop integrated service programs. While the vast

majority of prisons have substance abuse programs, only a

small minority of prisoners with substance use disorders get

access to any addiction treatment (CSAT, 2005b). The

likelihood of access to COD programs is even smaller.

Courts and Supervision: Courts report increasing contact

with offenders with COD and drug court judges have found

that defendants with COD are more difficult to place into

treatment than those with a single disorder (Denckla &

Berman, 2001).

Social Welfare Settings That Afford an Opportunity

for COD Interventions

Homeless Services: More than two million U.S. citizens will

experience homelessness in a calendar year. Nearly 40

percent of these homeless persons have alcohol problems

and 26 percent have drug problems (Burt et al., 1999) with

recent estimates as high as 84 percent of men and 58

percent of women (North et al., 2004). Twenty percent of

homeless persons have SPD, and 25 percent have some form

of disabling health condition (CMHS, 2003). One third of

homeless persons have COD (North et al., 2001). While

integrated care has been cited as important to the recovery

of homeless persons with COD, few have access to it

(CMHS, 2003). Homeless people are disaffiliated and are not

often voluntary recipients of any kind of health services.

Thus, homeless persons with COD may remain undiagnosed

and untreated. This, in turn, can lead to continued

homelessness and further deterioration in physical, social,

and economic functioning.

Community Settings: Persons at high risk for—or in the early

stages of—SA/MH disorders often continue to function and

fulfill work, school, and family obligations (Klitzner et al.,

1992). The tendency of lay people to “normalize” early signs

of deteriorating functioning (Mechanic, 1978), combined

with the stigma attached to SA/MH problems and a lack of

familiarity with warning signs on the part of teachers,

supervisors, clergy, and parents, may lead to missed opportunities for early intervention. Significant levels of deterioration

in functioning and/or disruption may lead to punitive actions

rather than referral to helping resources.

3. What can be done in primary healthcare settings

to help persons with COD?

The Institute of Medicine report Improving the Quality of

Health Care for Mental and Substance-Use Conditions

(2006) highlights the strong link between mental and

substance use disorders and general health care. One of the

report’s overarching recommendations states, “Health care

for general, mental, and substance-use problems and

illnesses must be delivered with an understanding of the

inherent interactions between the mind/brain and the rest of

the body” (p. 9). COCE takes the position that a first step in

implementing this recommendation is to identify persons

with COD as a routine component of care in each of the

health settings discussed above. This position is based on

considerations of quality of care as well as cost recovery for

care providers and payors. Overview Paper 2, Screening,

Assessment, and Treatment Planning for Persons With CoOccurring Disorders (CSAT 2006), provides details on the

methods and procedures by which this identification can be

accomplished.

Figure 2: Screening For COD in Primary Care Settings

Depression

• Over the past two weeks, have you felt down, depressed, or hopeless?

• Over the past two weeks, have you felt little interest or pleasure in doing things?

CAGE (CAGE-AID)

1. Have you ever felt you should Cut down on your drinking (or drug use)?

2. Have people Annoyed you by criticizing your drinking (or drug use)?

3. Have you ever felt bad or Guilty about drinking (or drug use)?

4. Have you ever taken a drink (or a drug) first thing in the morning (Eye-opener) to steady your nerves or get

rid of a hangover?

Sources: Agency for Healthcare Research and Quality, 2002, 2004; Fiellin et al., 2000, p.1979.
Addressing Co-Occurring Disorders in Non-Traditional Service Settings 5

An efficient screening method for COD in primary care

settings is laid out in Figure 2. It combines two questions

related to depression with the four questions of the CAGE (or

CAGE-AID—adapted to include drugs). If these six questions

are used for screening, the depression screening items will

serve as a marker for a wide range of mental health issues

and the CAGE/CAGE-AID items will help identify substancerelated problems. Any single positive response should lead to

a thorough assessment by a mental health and/or substance

abuse professional. A positive response to both an item from

the depression questions and an item from the substance use

questions should lead to an assessment by a COD professional.

It is recognized that resources beyond screening and identification are not readily available in most primary health

settings, and inadequate financing for these basic services is

often a barrier (McLellan & Meyers, 2004). As such, community mental health and substance abuse systems of care must

be designed to support public and private health care

settings’ screening efforts with appropriately matched and

readily accessible assessment and treatment services delivered

within SA/MH programs.

A continuum of responses to persons with COD who appear

in health settings can be identified (NASMHPD & NASADAD,

1999):

• Identification and Initial Management is the minimum

level of responsibility. It involves screening for COD and

providing brief, structured, targeted advice to patients.

Referral of those with positive screens or serious symptoms, such as suicidal thoughts or trouble making sense,

may be necessary. The health setting retains responsibility

for the client’s general health care unless or until the client

is referred to a treatment facility that offers health care in

addition to COD services. Upon discharge from such a

facility, responsibility for general health care reverts back

to the original, referring setting.

• Collaboration is a formal process of sharing responsibility

for treating a person with COD, involving regular and

planned communication, shared progress reports, or

memoranda of agreement. In a collaborative relationship,

different disorders may be treated by different providers,

yet the roles and responsibilities of the providers are clear.

• Integration requires the participation of providers trained

in both primary care and SA/MH services to develop a

single treatment plan addressing all health conditions.

These providers continue their formal interaction and

cooperation in the client’s ongoing reassessment and

treatment.

Several considerations will determine where a given health

setting operates on this continuum. While the nature and

type of integration will vary by communities, it has been

proposed that the SA/MH system take the lead in developing

the plan (CSAT, 2000a). Other considerations include

resources, funding, clinical interest in COD, and the availability of other COD resources in the community. Treatment

Improvement Protocols (TIPs) 37, Substance Abuse Treatment for Persons With HIV/AIDS (CSAT, 2000b) and 42,

Substance Abuse Treatment for Persons With Co-Occurring

Disorders (CSAT, 2005a), address how providers with

specialized training for “triply diagnosed” clients have been

successful in addressing COD. For example, the HIV Integration Project of The CORE Center in Chicago, Illinois, (CSAT,

2005a) is a good example of a local integrated service

response to health and COD needs. There are as yet no data

to favor one approach over another; agencies will address

COD issues to the extent that their resources allow and can

participate in advocating and soliciting additional funding to

support enhanced COD interventions.

4. What can be done in other non-SA/MH settings to

help persons with COD?

Like primary health settings, other settings can also serve as

gatekeepers for the SA/MH system. These settings provide an

opportunity to recognize persons who may have COD and to

engage them in a process that leads to referral for further

assessment and integrated treatment. This recognition,

engagement, and referral approach requires strong partnerships with community SA/MH providers. These approaches

typically require the oversight of a multidisciplinary community planning group, training for frontline staff, the development of specific referral guidelines, and easy access to

welcoming clinical settings.

Public Safety and Criminal Justice Settings

Innovative police responses to persons with COD illustrate a

recognition, engagement, and referral approach. Law

enforcement is often the initial point of contact for persons

with COD who may have violated a public ordinance,

committed a crime, or raised the suspicions of other citizens

or police through unusual, disruptive, and/or bizarre behavior. During the last 10 years, police-based specialized

responses, most notably the Crisis Intervention Team, have

been implemented across the country (Reuland, 2004). In

these models, police receive intensive training to recognize

and engage persons with COD, with the goal of increasing

access to treatment and support services and diversion from

criminal justice settings.

Problem-solving courts, such as drug courts and mental

health courts, have been developed as a response to the

growing influx of persons with COD in the court system.

These settings have recognized the need to develop specialized responses to the defendant with COD (Peters & Osher,

2004). Such responses include specialized training for court
6 Addressing Co-Occurring Disorders in Non-Traditional Service Settings

personnel to help them identify people with SA/MH needs,

implementing specialized programming, and championing

community alternatives for these individuals. The goals of

these initiatives include an increase in public safety, better

quality of life for the consumer with COD, and a more

effective use of overtaxed criminal justice resources (Council

of State Governments [CSG], 2005).

Identification and management of COD within jails and

prisons mirror the complexity of providing care within

community settings. While the inmate with COD is legally

entitled to health care and can be more easily “engaged” in

treatment than those who are not confined, jail and prison

treatment resources are scarce (Fellner & Abramsky, 2003),

and integrated care programs are rare. Jails are attempting to

improve screening procedures for COD with the use of

standardized instruments administered by correctional staff

(Steadman et al., 2005).

Opportunities for brief motivational interventions exist, yet

the capacity of understaffed jail providers and inmates to

develop a strong therapeutic alliance is limited. Such collaborative efforts as the Vermont Departments of Health and

Corrections coordinate programming to identify, assess, and

treat offenders with COD in their criminal justice system

(CSG, 2005). Sacks and colleagues (2004) describe a

modified therapeutic community model that has shown

significantly lower reincarceration rates for persons with COD

leaving incarcerated settings compared to those who

received MH treatment only. Because of the stigma associated with the combination of COD and a criminal record,

specialized programming is necessary to ensure successful

transition to communities on release (CSAT, 2005a).

Social Welfare Settings

Outreach is often required in order to reach individuals who

are marginalized, isolated, alone, or homeless (Federal Task

Force on Homelessness and Serious Mental Illness, 1992). A

rich history of outreach efforts to marginalized individuals

exists in the United States (Lam & Rosenheck, 1999;

Tommasello et al., 1999). By starting with what the

marginalized person values and desires, it is possible to

develop a relationship that can address associated conditions

such as mental illness and/or addiction. Once engaged, the

individual will benefit from the same integrated interventions

associated with positive outcomes in other clinical settings.

Central to the process of outreach and engagement is the

establishment of a “helping relationship.” Core characteristics

of this relationship include mutual trust and respect, tolerance and flexibility, patience and realism, and being helpful

in the eyes of the consumer (Winarski, 1998). Sacks and

associates (2002) have described adaptations of therapeutic

communities in shelters that use the peer community and a

focus on mutual self-help as a starting point to engage

homeless persons with COD. Once engaged, providing

access to supportive housing can have a powerful effect on

outcomes for homeless persons with COD (CSAT, 2005a).

Community Settings: Schools, workplaces, community

groups, families, and friendship networks are the settings in

which individuals spend the most time. Signs of COD are

likely to manifest in these settings, although they may not be

recognized as such. Student and employee assistance

programs, informational kiosks at community events,

pastoral counseling, and other similar intervention methods

offer the potential for early identification and referral of highrisk individuals before serious COD-related problems emerge

(Klitzner et al., 1992).

FUTURE DIRECTIONS

For a variety of reasons, COD is currently neither widely

recognized nor well addressed in the settings discussed in

this paper. Wider dissemination on the use of screening and

identification techniques appropriate to these settings could

encourage programs to develop efficient referral mechanisms

and/or more onsite COD interventions. Demonstration

programs have shown that identification and effective care

are possible, but access to these innovations is not widespread. The activities that staff in these settings need to

perform—recognizing signs and symptoms, making referrals,

and the like—can be learned, although training would need

to be expanded to include primary care practitioners, justice

staff, and social welfare personnel. Excellent models, some

of which are cited in this paper, are available for communitylevel adoption. Future work should address issues of dissemination and implementation of these models.

Realizing the goal of “No Wrong Door” requires increased

awareness of COD in non-SA/MH settings, fostering enlightened self-interest in COD issues, and establishing the

community networks, teamwork, and systems required to

meet the needs of persons with COD. SA/MH providers

should take the lead in creating a continuum of COD services

to support efforts in non-SA/MH settings.
Addressing Co-Occurring Disorders in Non-Traditional Service Settings 7

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COCE National Steering Council

Richard K. Ries, M.D., Chair, Research Community

Representative

Richard N. Rosenthal, M.A., M.D., Co-Chair,

Department of Psychiatry, St. Luke’s Roosevelt

Hospital Center; American Academy of Addiction

Psychiatry

Ellen L. Bassuk, M.D., Homelessness Community

Representative

Pat Bridgman, M.A., CCDCIII-E, State Associations of

Addiction Services

Michael Cartwright, B.A., Foundations Associates,

Consumer/Survivor/Recovery Community

Representative

Redonna K. Chandler, Ph.D., Ex-Officio Member,

National Institute on Drug Abuse

Joseph J. Cocozza, Ph.D., Juvenile Justice

Representative

Gail Daumit, M.D., Primary Care Community

Representative

Raymond Daw, M.A., Tribal/Rural Community

Representative

Lewis E. Gallant, Ph.D., National Association of State

Alcohol and Drug Abuse Directors

Andrew L. Homer, Ph.D., Missouri Co-Occurring State

Incentive Grant (COSIG)

COCE Senior Staff Members

The CDM Group, Inc.

Rose M. Urban, LCSW, J.D., Executive Project Director

Jill G. Hensley, M.A., Project Director

Anthony J. Ernst, Ph.D.

Fred C. Osher, M.D.

Michael D. Klitzner, Ph.D.

Sheldon R. Weinberg, Ph.D.

Debbie Tate, M.S.W., LCSW

National Development & Research Institutes, Inc.

Stanley Sacks, Ph.D.

John Challis, B.A., B.S.W.

JoAnn Sacks, Ph.D.

National Opinion Research Center at the University

of Chicago

Sam Schildhaus, Ph.D.

Andrew D. Hyman, J.D., National Association of

State Mental Health Program Directors

Denise Juliano-Bult, M.S.W., National Institute of

Mental Health

Deborah McLean Leow, M.S., Northeast Center for

the Application of Prevention Technologies

Jennifer Michaels, M.D., National Council for

Community Behavioral Healthcare

Lisa M. Najavits, Ph.D., Trauma/Violence Community

Representative

Annelle B. Primm, M.D., M.P.H., Cultural/Racial/

Ethnic Populations Representative

Deidra Roach, M.D., Ex-Officio Member, National

Institute on Alcohol Abuse and Alcoholism

Marcia Starbecker, R.N., M.S.N., CCI, Ex-Officio

Member, Health Resources and Services

Administration

Sara Thompson, M.S.W., National Mental Health

Association

Pamela Waters, M.Ed., Addiction Technology

Transfer Center

Mary R. Woods, RNC, LADAC, MSHS, National

Association of Alcohol and Drug Abuse

Counselors

COCE Senior Fellows

Barry S. Brown, M.S., Ph.D., University of North

Carolina at Wilmington

Carlo C. DiClemente, M.A., Ph.D., University of

Maryland, Baltimore County

Robert E. Drake, M.D., Ph.D., New HampshireDartmouth Psychiatric Research Center

Michael Kirby, Ph.D., Independent Consultant

David Mee-Lee, M.S., M.D., DML Training and

Consulting

Kenneth Minkoff, M.D., ZiaLogic

Bert Pepper, M.S., M.D., Private Practice in Psychiatry

Stephanie Perry, M.D., Bureau of Alcohol and Drug

Services, State of Tennessee

Richard K. Ries, M.D., Dual Disorder Program,

Harborview Medical Center

Linda Rosenberg, M.S.W., CSW, National Council for

Community Behavioral Healthcare

Richard N. Rosenthal M.A., M.D., Department of

Psychiatry, St. Luke’s Roosevelt Hospital Center

Douglas M. Ziedonis, M.D., Ph.D., Division of

Psychiatry, Robert Wood Johnson Medical School

Joan E. Zweben, Ph.D., University of California -

San Francisco

Affiliated Organizations

Foundations Associates

National Addiction Technology Transfer Center

New England Research Institutes, Inc.

Northeast/IRETA Addiction Technology Transfer Center

Northwest Frontier Addiction Technology Transfer Center

Pacific Southwest Addiction Technology Transfer Center

Policy Research Associates, Inc.

The National Center on Family Homelessness

The George Washington University
COCE Overview Papers*

“Anchored in current science, research, and practices in the field of co-occurring disorders”

y Paper 1: Definitions and Terms Relating to Co-Occurring Disorders

y Paper 2: Screening, Assessment, and Treatment Planning for Persons With Co-Occurring Disorders

y Paper 3: Overarching Principles To Address the Needs of Persons With Co-Occurring Disorders

y Paper 4: Addressing Co-Occurring Disorders in Non-Traditional Service Settings

y Paper 5: Understanding Evidence-Based Practices for Co-Occurring Disorders

*Check the COCE Web site at www.coce.samhsa.gov for up-to-date information on the status of overview papers in

development.

For technical assistance:

visit www.coce.samhsa.gov, e-mail coce@samhsa.hhs.gov, or call (301) 951-3369

A project funded by the

Substance Abuse and Mental Health Services Administration’s

Center for Mental Health Services and Center for Substance Abuse Treatment