From the Board
January 2004

Focusing on co-occurring disorders

Over the past 30 years, as the care and treatment of persons with serious mental illness has shifted from the institutional state hospitals system to the community, one of the most notable trends has been the dramatic increase in the number of persons with co-occurring psychiatric and substance abuse disorders. The stressors of community life, together with the acute shortage of effective treatment, residential and rehabilitation services, has led too often to "self-medication" with illegal substances or alcohol that only exacerbate pre-existing psychiatric conditions. While reliable data is hard to come by, many programs that work with persons with serious mental illness report co-occurring substance abuse rates as high as 80%.

The seriously mentally ill who have co-occurring substance abuse represent a significant challenge to mental health and substance abuse programs. Many of the most successful substance abuse programs utilize the "therapeutic community" approach in which clients are sometimes subjected to very aggressive behavioral techniques, and while the so-called "modified therapeutic communities" have altered the model to be less aggressive, the basic approach of breaking down an individual's defenses to help re-build them as "clean and sober" clearly has its limitations with the seriously mentally ill. Similarly, mental health programs, with their clinical paradigm, are often at a loss in working with their clients' substance abuse problems.

Over the years, advocates and some program administrators have called for a major initiative to address the needs of consumers with co-occurring disorders. The reality of two separate systems—mental health, regulated and funded by the State Office of Mental Health (OMH) and substance abuse, funded and regulated by the State Office of Alcoholism and Substance Abuse Services (OASAS)—has been a major barrier in creating programs and solutions to address the needs of co-occurring consumers. And while research has confirmed that integrated mental health and substance abuse treatment greatly improve outcomes for consumers, the practical work of creating such programs has seriously lagged behind in New York State.

In 1998, OMH and OASAS created an Interagency Workforce to plan and implement co-occurring initiatives. Simultaneously, The New York Model was published, a framework that envisioned a four-quadrant structure: persons with low severity mental illness and substance abuse (Quadrant I) would be treated in the generic primary care system; persons with high severity mental illness and low severity substance abuse would be treated in the mental health system (Quadrant II), and persons with high severity substance abuse and low severity mental illness would be treated in the substance abuse system (Quadrant III). Quadrant IV, containing persons with high severity mental illness and high severity substance abuse, would be assigned to a self-described No Man's Land, the responsibility of the "joint" mental health and substance abuse systems. While many advocates applauded the New York Model as a beginning conceptualization, they were quick to point out that the ominous-sounding No Man's Land pointed to the need to break down the barriers between OMH and OASAS to create a new service system.

In May of 2001, a Quadrant IV Task Force Report was issued containing a vision of integrated services. The report encompassed both treatment and residential components, recognizing that substantial new resources would have to be made available to mental health agencies to develop the competencies needed to provide integrated mental health and substance abuse treatment. While OMH and OASAS have committed themselves to pursuing the Quadrant IV Report recommendations, none of the promised demonstration programs has yet to materialize. What has occurred is some initial, badly needed cross training for staff of mental health and substance abuse agencies and the deployment of a small number of staff throughout the state to develop local plans for co-occurring services.

With co-occurring disorders being so prevalent, it is especially important for NAMI and family members to monitor closely the state's efforts in this area. Clearly, additional funding is needed for enhancements to both residential and treatment services. Equally as important is the breaking down of barriers between OMH and OASAS so that the provider community is not hamstrung by regulatory requirements that may protect bureaucratic turf, but at the cost of severely limiting agencies' abilities to provide effective, integrated treatment. Only when the Governor's office and state legislature take the lead in reshaping the system will we see any real progress in this high-priority area.

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