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December 2004 – Tips & Topics

Volume 2, No. 8
December 2004

In this issue
– Until Next Time

Welcome readers!

As usual, I operate under the pressure of deadlines. Welcome to this last edition of 2004 as I scurry to get ready for the holidays. Perhaps you are more organized than me this year.


This month it was nice to be able to be in my home state of California for a couple of days focusing on the what and hows of integrating services for people with co-occurring substance use and mental disorders. When a large city and county like San Francisco, and a large State like California, starts to get serious about co-occurring disorders and dual diagnosis (or whatever your region calls it – MICA, CAMI, MISA, SAMI, MICD, dual disorders) that is something to celebrate. As I participated in those two days, I was reminded of a few concepts and resources that I want to share.


  • Integrated treatment for co-occurring disorders is about services, not organizational charts.

The debate goes on from county to county, state to state, Federal agency to Federal agency: Should substance abuse agencies be organizationally integrated with mental health into one behavioral health agency? The arguments for organizational and financial coordination and efficiencies seem rational and timely. Equally compelling are fears that the much larger and longer established mental health bureaucracy and budget will swamp and drown out the hard won gains and priorities for addiction treatment.

I’ve trained and consulted in systems that have either organizationally merged, or remained separate entities. It is clear that the real focus needs to be on how to integrate services so that the consumer, client, patient, customer gets what they need. Attitudes, knowledge and skills will not blossom to serve dual diagnosis clients well just because the organizational chart changes one way or the other.

“Integrated treatment is the interaction between the mental health and/or substance abuse clinician(s) and the individual, which addresses the substance and mental health needs of the individual.”

(From page vi in “A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders” 2002, from the Substance Abuse and Mental Health Services Administration (SAMHSA). Resource: )

So in whatever system you find yourself – combined behavioral health division, or separate addiction and mental health departments – check to see if at the consumer level, there really is integrated treatment or not.

Question checks:

1. To what degree do consumers experience their care as One Team, One Plan for One Person? Or do they fall through the cracks, bounced around from one clinician or case manager to the next with everyone, including the client, being clueless on what the integrated treatment plan might be?

2. Do you really mean, “Every door is the right door,” so that wherever clients call, they receive knowledgeable and welcoming assessment and service of their needs? Or are they greeted with confusing voice mail prompts, directives to call the other number as “we don’t take suicidal people or anyone on Xanax or Klonopin?”

3. Can people with substance use problems only get a psychiatric consultation and medication evaluation if they have a major mental illness by DSM-IV codes? Can a heroin-addicted consumer only get inpatient detoxification and medication support by exaggerating depressive and suicidal thoughts to the level of imminent danger?

  • The Co-Occurring Center for Excellence (COCE) is an up and coming resource for Co- Occurring Disorders.

In September 2003, the Substance Abuse and Mental Health Services Administration (SAMHSA) launched the Co-Occurring Center for Excellence (COCE). Its vision was to become a leading national resource for the field of co-occurring mental health and substance use disorder treatment. The mission of COCE is threefold: (1) to transmit advances in treatment at all levels of 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 treatment and program innovation into clinical practice. COCE consists of national and regional experts who serve to shape COCE’s mission, guiding principles, and approach. I am pleased to be one of the Senior Fellows assisting in the development of the COCE.

In the near future look for the COCE Overview Papers (OPs). These will be short, concise, and easy-to- read introductions to state-of-the-art knowledge in co-occurring disorders (COD). The intended audiences for these OPs are policymakers at the State and local levels, their counterparts in American Indian tribes, administrators of substance abuse and mental health agencies, and providers of wrap-around services. Sixteen topics have been selected for OPs based on input from SAMHSA, States, the COCE Steering Committee, and Senior Fellows.

These topics include:
Definitions, Terminology, and Nosology;
Overarching Principles;
Screening, Assessment, and Treatment Planning;
Epidemiology of Co-Occurring Disorders;
Services Integration;
Workforce Development and Training;
Financing Mechanisms;
Systems Integration and more.

Resource: For more information on the COCE, see: cle4_4.htm. A technical assistance Web site is forthcoming. You can contact the COCE at (301) 951-3369, or e-mail:


Usually the Skills section focuses on individual clinician skills. But this time, I will highlight some staff, program and systems issues related to Co- Occurring Disorders.


  • Normalize conflict in the team. If there aren’t disagreements, someone is wimping out and not advocating for their beliefs.

It is highly unlikely that you can assemble a team of mental health and addiction treatment professionals, (some of whom are in their own personal recovery) without there being conflict over when, what ,and if to use medication. Or on how to deal with substance use while in treatment.. Or on whether to immediately detox a long time alcohol-dependent, Klonopin user who believes it is absolutely necessary for his anxiety disorder.. The problem isn’t the fact of disagreements or conflict. The problem is if you don’t have a functioning conflict resolution policy. Practice disagreeing without being disagreeable:

Doctor, would you be willing to share with me your evaluation and history data you got, so I can understand the information I got from the client? I am concerned that the addictive sleeping medication you have prescribed clashes with my sense of the evaluation, being that the client has a severe addiction illness. I want to be sure I am clear on our work together with this client.”

If the physician responds that he/ she was unaware the patient was using substances to any great extent, let alone substance-dependent, then your questions have provided more comprehensive information. The physician may be aware of the substance use problem, but is using the potentially addicting sleeping medication only during the initial detox phase as an engagement strategy. You might feel more comfortable leaving things alone, and seeing what happens.

Question Checks:

1. Check if you have a conflict resolution policy.
2. Do you know where it is and what it says?
3. Do all team members know how to use the policy?

  • Everybody has a territory, but nobody has a kingdom.

When I was part of Parkside Medical Services (a large multi-program, multi-state addiction treatment system that has now largely disintegrated) this was one of the many meaningful values of the company’s Mission, Vision and Values. Programs need the gut, intuitive wisdom of the recovering staff members with their spiritual commitment to recovery. To complement that, they also need the objective skepticism of the mental health professional skilled in living with diagnostic ambiguity. It may be quite a while before further evaluation and time make it clear what the best course of treatment should be.

Integrated treatment needs programs that provide a “kingdom” of diverse services, levels of care, wet, damp and dry living supports, engagement and motivational services, medications, case management, mutual help groups, community resources and the list goes on. Each of our territories are critical, but only as they function in harmony with the whole.

Question Checks:

1. What is your territory?
2. Can you advocate for it without competitiveness and ill will?
3. How can all the territories in your region work together to create the kingdom co-occurring disorders deserve?


In a few weeks I will travel to Sydney, Australia to celebrate my mother’s 90th birthday. She is gathering a hundred or so friends and relatives at a restaurant to mark this important milestone for a woman in incredible health and mental well-being. I hope I have half her energy and cognitive ability, when I am 90.

A close relative was also planning to attend the celebration, but she cannot now make it. A mother of three young boys, she was oblivious to the fact that she had a rare form of malignant fat cell cancer. She had removed what appeared to be a simple lipoma on her chest wall. She has done remarkably well with her positive attitude both before and after the subsequent, extensive surgery to remove all cancer cells. I hope I have half her positive attitude if I ever am ill.

In this season of giving and receiving, this year has reinforced what all of us who are in the second half of our life have come to appreciate. The gift that has the most attraction for me is the gift of good health. This year, my loved ones have reminded me through their example, that in sickness or in health, an attitude of gratitude speaks volumes.

I wish you good health for 2005- in every aspect of your life and your loved ones.


It is gratifying to know that sometimes training events actually end up helping the people we serve, as well as the participants. This is a positive experience- a nice way to end 2004.

Dr. Mee-Lee,
I attended the trainings you held on September 22 and 23 in Ann Arbor, Michigan. I was the guy who performed “Jimmy” in the second day’s role-play. I want to thank you again for an inspiring and genuinely helpful training, and share with you a small success story.

I went to see a client (whom I’ll call Bill) the day after the training. This was my first time meeting the client after his discharge from a state psychiatric hospital, where he’d been treated for three months. My goal was simply to get to know him and his family a bit better, and also to get some sense of what he wanted to accomplish in his work with the ACT team I’m part of.

When I asked what he wanted his treatment to accomplish, his response was, in a sense, what we might call delusional and grandiose. “I would like to have greater influence over lawmakers,” he said, “to get stricter penalties against pedophiles”. Before his recent hospitalization, Bill had gone on a hunger strike in the aim of winning this sort of influence. Moreover, he believed that he could identify pedophiles by a certain “pattern” on their faces, leading to some heated verbal altercations when he accused such people.

Before taking your training, I think my response would have been something like, “Well, that’s a pretty high-level issue. How about we talk about something a little smaller and easier to accomplish?.” In other words: Let’s ignore that what you just said is kind of crazy and therefore invalid, and that I really don’t know how to work with that, and let’s get back to the things that are important to my program, like you taking your meds and staying out of the hospital.”

Instead I said, “How do you think we could help you with that?”

Bill responded, “I don’t know, I think I need to be more presentable.”

AH-HA! So there we were. Instead of deflecting him, I ask one question, and we’re back in the territory of what ACT can actually help with. “What would it mean to be more presentable?” I asked. And from there we got into a conversation about the importance of being clear-minded, of how going in and out of a psychiatric hospital would reduce his credibility on social issues (not fair, sure, but true), and how “being pushy” in the past made people believe he was out of control and landed him in the hospital.

The result: Bill sees taking his medications and working closely with us as a way of working on being presentable, stable, and credible.

The rest of the meeting went much the same. He identified two more goals, all of them “problematic” from a treater’s viewpoint (he wants to drive, and he wants to return to a clubhouse that has a trespassing order against him). In each case, by listening and asking questions, we were able to find some common ground that motivated him *and* satisfied the safety aims of my program.

I look forward to practicing motivational techniques and improving my skills. It’s very exciting stuff. I’ve prided myself on being quite skilled at interacting with acutely and chronically psychotic clients, and I’ve done a lot of good work at forming treatment relationships in a general way and handling crises, but these techniques show great promise at making a client’s treatment plan relevant and getting them more viscerally involved.

Thanks again,

John Gonzalez
Washtenaw Community Health Organization
Ypsilanti, Michigan

Until Next Time

Happy Holidays and I’ll talk to you next year.


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