Building Bridges:
Co-Occurring Mental Illness and Addiction: Consumers and Service Providers,
Policymakers, and Researchers in Dialogue
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Recommendations
The second day of the dialogue focused on consolidating the themes and individual
ideas into specific recommendations. Participants outlined specific, action-oriented
steps under each of nine major recommendations. These are the nine recommendations:
- Form
and maintain healthy, consumer-driven partnerships in policymaking, research,
and service delivery.
- Embed a whole-person focus in research and service delivery.
- Transform workforce development, emphasizing peer-based approaches.
- Expand programs to reduce stigma and discrimination against underserved
populations.
- Create incentives for coalition building.
- Engage actively in public awareness and education.
- Support appropriate policy for systems change.
- Support collaborative research.
- Redesign the reimbursement system.
Many recommendations were directed to SAMHSA in particular. However, a number
of recommendations were directed to providers and consumers, and to the field
in general.
- Form and Maintain Healthy, Consumer-Driven Partnerships in Policymaking,
Research, and Service Delivery.
1.1.1. Develop accountability mechanisms that track consumer involvement.
Mandate use of these mechanisms in requests for proposals for research and
programs funded by SAMHSA, NIH, NIDA, and other Federal agencies.
1.1.2. Use the Ryan White Act as a model to assure consumer participation
when allocating funds.
1.2. Increase the number of consumers/survivors participating on advisory
councils and panels.
1.2.1. Review the guidelines for consumer participation on advisory panels
and councils during SAMHSA’s reauthorization process
1.2.2. Include at least two consumer/survivor representatives on the SAMHSA
and CMHS National Advisory Council (in addition to participation on any subcommittees
that have been formed).
1.3. Increase consumer involvement at State and local levels in the design
and conduct of research, in the development of toolkits, in participation on
boards of mental health centers, in working with local providers, and in other
areas.
1.4. Train and support consumers asked to serve on advisory groups and participate
in partnerships. Consumers may be inexperienced with these kinds of jobs; do
not support tokenism, or set people up for failure. Mentors, orientation programs,
and other supports should be available for those asked to participate.
1.5. Include consumers as grant reviewers to help in the scoring of SAMHSA
grant applications. Ask grantees to demonstrate, account for, and evaluate
consumer involvement in grants.
1.6. Clarify the definition of “consumer.” Assume that most people have a
disorder, and ask people to disclose that they are a non-consumer. The thinking
should be changed to “we’re all co-occurring until proven otherwise.”
2. Embed a Whole-Person Focus in Research and Service Delivery.
2.1. Create a resource pool of effective screening and assessment tools, particularly
those that help providers and consumers understand the whole person.
2.2. Use a treatment team approach; encourage providers to assess a person’s
strengths as well as weaknesses, and to follow up with each other and the consumer
about how strengths are being reinforced and weaknesses are being addressed.
2.3. Ask research questions and clinical questions about the inner dynamics
and personal experience of recovery that drive the recovery itself.
2.4. Require data sharing across systems.
2.5. Train consumers in the Wellness Recovery Action Plan (WRAP) program,
and train them to become facilitators and trainers, so consumers can teach
other consumers about these tools.
2.6. Improve general medical health care coordination with substance abuse
and mental health issues.
2.6.1. Incorporate ceremony and ritual into treatment.
2.6.2. Recognize people as “multiply-abled” and not “multiply-disabled.”
2.6.3. Include vocational rehabilitation in the continuum of care—not as a
collateral or extra type of service.
2.7. Use advance directives in all co-occurring treatment and services programs,
and develop national standards for advance directives.
2.8. In vocational rehabilitation service programs, focus on the development
of careers.
2.9. Create “one-stop shopping” for co-occurring services.
2.10. Create incentives for communities/neighborhoods to allow housing programs
for persons in recovery from co-occurring illnesses.
3. Transform Workforce Development, Emphasizing Peer-Based Approaches.
3.1. Initiate a 10-year SAMHSA workforce development plan. The plan would
include scholarships and loan forgiveness programs for serving in the field.
The plan would also call on SAMHSA to demonstrate leadership in changing accreditation
requirements of the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) and other accrediting organizations to ensure that co-occurring disorders
are included in service delivery.
3.2. Design and support a recruitment campaign for peer support specialists.
Actively recruit people with addictions and psychiatric conditions to work
in the field. Create specialized training and certification for people in recovery
to work in the field.
3.3. Place a strong emphasis on new curriculum development on co-occurring
disorders across academic social work, psychology, psychiatry, nursing, and
other programs at colleges and universities.
3.4. Develop licensure requirements for behavioral health and substance abuse
treatment in collaboration with university graduate programs.
3.5. Establish credentials for specialists in substance abuse/mental health
fields, that is, for professionals who work with special populations.
3.5.1. Increase education about special populations, particularly older adults.
3.5.2. Support gender minority and sexual minority sensitivity training.
3.6. Increase block grant flexibility to add workforce development plans;
rely on incentives rather than sanctions in proposed plans. Design incentives
to look beyond Quadrant IV (of the National Association of State Alcohol and
Drug Abuse Directors (NASADAD)/National Association of State Mental Health
Program Directors (NASMHPD) conceptual framework), e.g., early identification/prevention
and marital counseling.
3.7. Assure that workforce development programs apply to rural areas. Base
workforce development initiatives regionally.
4. Expand Programs to Reduce Stigma and Discrimination Against Underserved
Populations.
The following recommendations recognize the importance of balancing the need
for focusing on specific needs of underserved populations, while at the same
time moving toward genuinely including all special populations in the community-at-large.
4.1. Adopt, at Federal and State levels, through legislation or regulation,
the language on nondiscrimination adopted by the State of Texas.
4.2. Improve access for underserved populations by encouraging multidisciplinary
team approaches to outreach, evaluation, and treatment, including training
of gatekeepers to obtain access to these specialized services.
4.3. Address the needs of special populations in the publication of co-occurring
toolkits.
4.4. Recognize older adults as a special population. The differences between
the needs of older adults and the regular population are as significant as
the differences between children and the regular population. “Nondiscrimination”
is not sufficient; older adults must be identified as a special population.
4.5. Compile data on sexual minority and gender minority discrimination. Gender
and sexual minorities experience discrimination “in all four quadrants,” yet
sufficient information has not been collected about this issue.
4.6. Increase training, education, and outreach for Native Americans.
4.7. Reduce the stigma of being an ex-inmate. Professionals may prefer not
to deal with, or may not trust, many ex-inmates.
4.7.1. Allocate funding for housing and provide training for ex-inmates.
4.7.2. Implement life skills and other training programs for incarcerated
persons while they are still in jail/prison.
4.8. Train agency and program staff in “Therapeutic Community,” “Milieu Management,”
and other approaches that welcome persons with co-occurring disorders and support
consumer-driven programs.
4.9. Ensure that persons with co-occurring disorders are represented in all
SAMHSA activities and groups, rather than seeing them as a sub-specialty group.
4.10. Support interpretation of the Americans with Disabilities Act (ADA)
as covering mental and substance abuse disabilities.
5. Create Incentives for Coalition Building.
5.1. Include coalition building as a grant incentive or requirement.
5.2. Create incentive grants, like the State Incentive Grants (SIGs), for
national substance abuse and mental health advocacy organizations to work together
on co-occurring issues.
5.3. Form coalitions with the vocational rehabilitation disability community.
5.4. Create a resource pool of materials that relate what organizations and
agencies in other States are doing in regard to policy, training, and curriculum.
5.5. Ensure that the requests for proposals for SAMHSA/CMHS-funded Consumer
and Consumer Supporter Technical Assistance Centers require these centers to
focus on co-occurring issues and cultural competence.
6. Engage Actively in Public Awareness and Education.
6.1. Enter into direct dialogues with media representatives. Develop more
contacts to change media stereotypes.
6.2. Emphasize the message that “recovery is possible,” and show the face
of co-occurring in public awareness campaigns, using media and the arts.
6.2.1. Create campaigns such as “Recovered Faces in High Places.”
6.2.2. Encourage the pharmaceutical companies’ advertising campaigns to place
a softer, gentler face on psychiatric and co-occurring issues.
6.3. Become more visible and assertive in the community. Avoid “preaching
to the choir” in anti-stigma campaigns; go to other groups and into the center
of the community.
6.4. Think strategically about the use and impact of language.
6.4.1. Distinguish “recovery,” which is a personal, individual process, from
“wellness,” which involves families and the whole community. The community
must buy into wellness for appropriate policy to be adopted.
6.4.2. Think in terms of three simultaneous levels of impact—individual, family,
and community/society.
6.4.3. Make sure that the language we use, and the way we phrase things, does
not get us into a box. For example, “substance abuse” has become merely a catch-all
phrase for all addictions and reinforces an image of willful misconduct, while
“substance dependence” is more strongly associated with mental illness in co-occurring
disorders.
6.4.4. Define “family” according to the individual’s circumstances to ensure
that services are not limited, especially during crisis situations.
6.5. Apply a co-occurring agenda to the Emergency Medical System.
6.6. Conduct assessments of co-occurring disorders to get an adequate picture
of the situation across society—the incidence of co-occurring is much greater
than what is normally portrayed.
6.7. Identify appropriate Web sites and develop a process to efficiently exchange
links and get information to organizations.
6.8. Encourage local efforts that integrate people with co-occurring issues
into the community and encourage direct interaction with others to help increase
their quality of life.
6.8.1. Conduct all community outreach alongside people with co-occurring illnesses.
6.8.2. Have professionals and people in recovery jointly make presentations
to community groups and others.
7. Support Appropriate Policy for Systems Change.
7.1. Include language in Federal policy proposals that supports or requires
co-occurring approaches, including SAMHSA’s reauthorization, as well as authorization
for the National Institutes of Health (NIH) and the Centers for Medicare and
Medicaid Services (CMS).
7.1.1. Look for opportunities to include appropriate language in Federal and
State policy similar to that used in Texas. Use caution, because there is some
risk, especially at State levels, of policy that places more restrictions and
allows fewer community-based approaches.
7.1.2. Become more proactive in reviewing and developing policy in general.
7.2. Encourage substance abuse/mental health planning committees to work together
in developing block grant proposals. Develop guidelines that allow States flexibility
in designing specific mechanisms that support co-occurring approaches, and
that take differences in substance abuse and mental health funding into account.
Specific ideas to consider:
7.2.1. Have block grant proposals reviewed by a consumer committee.
7.2.2. Allocate the same amount of funding for older adults as for children.
7.2.3. Establish an advisory and planning council when designing a State’s
substance abuse Performance Partnership Grant (PPG), or add substance abuse
to the mental health planning council.
7.3. Advocate for Medicaid guidelines on co-occurring that do not support
the mental health/substance abuse departmental split at the State level—to
reduce the administrative nightmare of working with two systems.
7.4. Examine the need for paramedics to be able to petition for involuntary
treatment.
7.5. Develop guidelines within SAMHSA for encouraging consumer advocate input
on policy.
7.6. Change SAMHSA’s Center for Substance Abuse Prevention’s (CSAP’s) authorization
to include prevention of behavioral health disorders.
8. Support Collaborative Research.
8.1. Promote research as an active, accountable partnership between providers
and consumers, and create funding mechanisms that support this concept. Research
and evaluation should be an ongoing, building process, integrating what is
being learned with training of personnel.
8.2. Establish a “toward evidence-based research” funding track to discover
where innovation is happening, so that research is not limited to traditional,
academic approaches.
8.3. Provide funding or other support for demonstration projects so that they
can be sustained after the research/demonstration phase.
8.4. Encourage NIH to develop its own “blueprint,” a 5-year plan to respond
to co-occurring disorders as SAMHSA has done.
8.5. Create a mechanism to support collaboration between NIH research funding
and SAMHSA service funding.
8.6. Set up projects with and through the Veterans Administration (VA).
8.7. Focus research efforts on ways to understand the process of treatment—what
is happening to a person’s self-esteem and personal growth during the treatment
process—as well as treatment outcomes. What are appropriate personal growth
indicators?
8.8. Demonstrate how cost—and cost savings resulting from research and service
delivery innovations—influences policy and planning.
8.9. Disseminate research findings to a wider audience beyond professionals
to consumers, to be more relevant and inform practice more quickly.
8.9.1. Present research results at conferences interactively to allow more
dialogue between consumers and providers.
8.9.2. Write, publish, and present research results in plain language.
9. Redesign the Reimbursement System.
9.1. Convene a SAMHSA Work Group—including provider and consumer stakeholders—to
comprehensively review the reimbursement structure for co-occurring disorders
and to develop a funding plan that supports the blueprint in the SAMHSA Report
to Congress (RTC).
9.1.1. Review the list of recommendations from this meeting and construct
a model of a system that focuses on the whole person, is multidisciplinary,
and is consumer-driven in approach.
9.1.2. Determine the principal bottlenecks in the present system and then
assess the cost factor/waste of maintaining the present system. Make it possible
to say, “Because of the various Federal and State requirements, in each State,
to provide $1 of service, it is costing us $X.”
9.2. Support some level of reimbursement of substance abuse services as well
as expand mental health services through Medicaid and Medicare reform.
9.3. Do not change Medicaid into a block grant.
9.4. Establish a new billing code, a new rate, and new program certification
for co-occurring services.
9.5. Permit SAMHSA and CMS reimbursement for multidisciplinary treatment planning.
9.6. Fund SAMHSA demonstration projects that make use of both private and
State treatment funds.
9.7. Construct a data system that can track funding across the various “silo”
agencies and systems. Make better use of technology.
DHHS Publication No. (SMA) 04-3892
Printed 2004
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