WEB CHAT:	When Addiction and Mental Disorders Co-Occur
HOST:	Dr. Thomas A. Kirk, Jr., Commissioner, Connecticut Department of Mental Health and Addiction Services
WHEN:	March 19, 2003, 3:00-4:00 pm EST
SPONSOR:	CSAT

After watching "When Addiction and Mental Disorders Co-Occur," you will likely have many questions on how to treat individuals with co-occurring and co-existing disorders.

• What issues or barriers are preventing the delivery of behavioral health and addiction treatment services to those with a co-occurring condition?
• What can be done to help those with co-occurring disorders gain access to behavioral health or addiction treatment?
• How big of a problem is the misdiagnosis of people with co-occurring disorders? What are the critical factors for assessing these disorders?
• How is the recovery process different for those with coexisting disorders?

You can ask these questions and more as part of a "live" online discussion with Thomas A. Kirk, Jr., Ph.D., Commissioner, Connecticut Department of Mental Health and Addiction Services, on Wednesday, March 19, 2003 from 3 to 4 p.m. EST. Be a part of a lively exchange with one of the country's foremost authorities on services for persons with addiction and mental disorders. Mark your calendar today and post your questions in advance using the box below.

Chat Transcript

Moderator: This chat will begin in 5 minutes. . .

Welcome to the Recovery Month 2003 Web chat. Our host today is Dr. Thomas Kirk, Commissioner, Connecticut Department of Mental Health and Addiction Services. Our topic is "When Addiction and Mental Disorders Co-Occur". This online discussion will highlight issues and promising practices associated with treating individuals with co-occurring and co-existing disorders.

Please note that the views and opinions expressed by non-CSAT staff members in the Web chats and Webcasts should not be interpreted as official CSAT policy, but as the views and opinions of the individuals participating in these events.

This question was previously submitted.

Q: What are some of the social biases that recovering drug addicts encounter on their route to recovery, and how do they affect the abuser?

Dr. Thomas Kirk: That is an interesting question because it highlights the stigma associated with persons recovering from substance abuse disorders. So often, the larger uninformed view is that the person who develops a problem with substance use is at fault and that even if they show signs of recovery, relapse is right around the corner. So from a social point of view, whether in one's family or a job setting, there is this expectation or perception that it is just a matter of time before things fall apart again. And so it is as if the standards for approval and accomplishment are higher to begin with. And I believe the biggest challenge to the person in recovery is to not buy into that thinking or perception. It is even worse if it turns out that a person has some type of criminal justice involvement as part of their substance use history. I will give an example. I once treated a young woman who was doing well in terms of her counseling, keeping her appointments at the clinic, and abstaining from substance use. Then, I didn't see her for a while and when I finally caught up with her and asked what was going on, she said that when she comes to this clinic people look at her as if she is a junkie. And she stated she did not feel like a junkie anymore.

Moderator: Please note that the views and opinions expressed by non-CSAT staff members in the Web chats and Webcasts should not be interpreted as official CSAT policy, but as the views and opinions of the individuals participating in these events.

This question was previously submitted.

Q: My 18-year-old son is in the middle of a full-fledged addiction problem. I cannot force him into a rehab center, and he does not want to quit. He is dying before my eyes and it is killing me to watch this. He threatens suicide if I call the police or try do anything to stop him. What can I do?

Dr. Thomas Kirk: Understandably, that is a very difficult situation. What I would suggest is you contact one of the treatment centers in your area and ask them whether they provide what is known as intervention services. You can do that in a confidential way without getting your son involved at first. What you will learn from someone at a good program is what the service would involve and how it could be done without causing your son additional problems. The person will also help you understand what people call the stage of readiness, which has to do with where the person is relative to a receptiveness to change. The person will listen to what you say about your son and where he may be at in that process and then give you clues as to what can be done to make him aware that he has a problem. You also may look for Al-Anon and Nar-Anon groups in your local area. The advantage of these groups is that they will give you support, too.

trompy: What is the best way to reach someone who is in recovery for alcoholism, but in denial about their own depression and dependence on prescription drugs?

Dr. Thomas Kirk: Part of it may be to understand what the person is doing, and effectively so, to maintain their recovery from alcoholism. The idea would be to help understand what the person's values are to maintain his or her abstinence. I would think with that as a knowledge base, signs of depression could be pointed out since it is not uncommon for substance abuse and depression to co-occur. In the course of doing that, I think the person involved will have greater awareness and acceptance of what depression is, and use the same methods used to maintain a recovery from alcoholism in addressing the depression. Without knowing the specifics of this situation, I can surmise that the addicted person may be greatly concerned that if they stop their medication for the depression, they would relapse into alcoholism. One additional point is that it is important to try to understand a person or help them to learn how to address assertive statements. An example would be to help them to understand or ask a question such as, "When you use your medication, how does that make you feel?" So it is a matter of raising awareness.

Moderator: This question was previously submitted.

Q: How can family members become involved in treatment, education, and support for one of their own with addiction and mental illness when health care providers are prevented from intervening as a result of patient confidentiality laws? Many times these patients refuse treatment and demand privacy of diagnosed information. This situation only encourages patients and families to live in a state of denial.

Dr. Thomas Kirk: I don't know where you live, but in Connecticut-where I live-there is an organization called the National Alliance on Mental Illness, Connecticut chapter, that offers counseling and information to families that want to know what they can and cannot have access to. Also, family members need to increase their communication with the identified patient. The result of this is that the patient could give consent if he or she felt the genuine concern behind the request. Or, the patient could offer information about why they don't want to share the information. The bottom line is that it is a trust issue, so the focus has to be on communication with the patient and understanding why he or she would be concerned and defensive.

trompy: How are people with co-occurring disorders treated in the workplace? Are there any model workplace programs that you know of?

Dr. Thomas Kirk: Not knowing where you are calling from, I can't give you a specific Employee Assistance Program (EAP); however, in many states there is a professional employee assistance program group association. I would suggest you check first with a group such as that to see how different EAP programs handle co-occurring issues. Then, depending on the employer and the first couple of sessions with an EAP person, the employee could help assure that the approach being taken is responsive to the person with the co-occurring illness.

nkyoung: Do you, or other participants, know of programs that are effectively implementing a "whole family" approach and addressing the needs of children of parents with co-occurring disorders-those who are at substantial risk of developing their own addiction and mental illness?

Dr. Thomas Kirk: Within Connecticut, we have funded a couple of different programs, usually with federal support from the Center for Substance Abuse Prevention (CSAP) that have developed effective approaches specifically for your question. I suggest you call the director of prevention services in my agency, Diane Harnad, at 860-418-6828. I will alert her that you are calling for this type of information. I would also imagine CSAP, which has a Web site (http://www.samhsa.gov), would be a great source of information about not only the tested models, but where they might be located throughout the country. Another source is ATTC, Addiction Technology Transfer Center, and there is one in New England at Brown University. The Web site covers all the centers in the US. Go to http://nattc.org and it will give the references for the ones around the country.

Moderator: This question was previously submitted.

Q: What are your thoughts on Connecticut's current attempt to train state employees to work with the dually-diagnosed clients versus privatizing these services to those already knowledgeable in the substance & psychiatric field? How do we truly provide effective, COMPETENT, services for the dually-diagnosed client? We have seen that in tight budget years, such as now, recommending services is not enough.

Dr. Thomas Kirk: Using Connecticut as an example, our state system for behavioral health services is a combination of state operated and privately funded programs, so we operate services and have about 250 private agencies under contract to provide services. Neither one has a monopoly on knowledge to treat co-occurring illnesses. Our approach is to say that whether it is a state-operated service; a hospital; an outpatient program; or one of our private, non-profits under contract, each of them have to be able to provide effective, competent service. So what we try to do is offer training for both state-operated and private, non-profit agencies. We provide continuing supervision after they finish training and set standards, whether through credentialing staff at the state operator's level or in a contracted agency. So we can determine or assess who is competent to do what. One of the things we like in Connecticut in helping in this regard is the American Society of Addiction Medicine (ASAM), which is known as the PPC-2. It helps determine the level of co-occurring disorder a person has and therefore the appropriate course of treatment. We make the distinction between a program and a person who is dually diagnosed who is "capable dual diagnosis enhanced," and those whose capability is restricted to addiction capability only (AOS). Dual-diagnosis capable refers to a program or person who is capable of working with a client who has a substance abuse disorder in the lesser mental illnesses, not the severe. Dual-diagnosis enhanced applies to persons or programs capable of effectively treating those with more serious psychiatric disabilities, schizophrenia, or bipolar. It is important to emphasize that these distinctions are not based so much on the diagnosis as they are on the severity of the symptoms the person shows. I think a final comment I would like to make is that even though a number of states are in difficult fiscal straits, including Connecticut, one should not be backing off of training, credentialing, or other options to ensure people have effective, competent services. So my point is, whether it is a state employee or a non-profit agency, my expectations are that a care provider is going to be able to provide the highest quality. One final point. We treat about 70,000 persons a year in the state-operated and private system in Connecticut. A good portion of those persons has some level of co-occurring disorder already and to move all those patients to one part of the system, whether it be state or private, would overwhelm it.

evincent: How best can treatment providers help someone who believes they have a problem with substance use but does not believe they also have a mental illness or vice versa?

Dr. Thomas Kirk: In my judgment, I am a psychologist by training, I have found that there are three essentials for effective treatment. First is to help the person get to the point where they agree that MAYBE they have a problem with either mental illness or substance abuse or both. Secondly, having achieved that, teach the person the tools that can be used to manage that illness or problem. And thirdly, show the person other people who are using these tools and are getting better as a result. The bottom line is you have to meet the person where they are at, and help them to get to where they need to go and maybe try to concentrate on things or areas that are important to that person . . . their job, relationships. Use those as a signpost or indicators of the problem the person is having and how (their problem) impacts those areas.

trompy: Do you think there is a different stigma attached to substance abuse addiction vs. mental illness? And if so, what is the cumulative stigma for those who have both?

Dr. Thomas Kirk: As the Commissioner of a state agency that works with people who have a psychiatric disability as well as those with substance use disorders, my experience is that there is more stigma in some sectors in relation to substance abuse because the perception is that the person brought it on themselves. (People think) if they wanted to stop, they could have and did not. With mental illness, it is easier to have people understand the biological basis of a psychiatric disability. So what people are missing is that if you are talking about a person with a psychiatric disability or a person with a substance abuse disorder, both of them involve a disease of the brain-the chemistry of the body-so it is not a social issue but a health care issue. Furthermore, the stigma is probably even greater if the person has a psychiatric and a substance abuse disorder, partially because of the view that such persons are more dangerous than those with just a psychiatric disability or solely a substance abuse disorder. So if you are looking at occurrences of violence or similar kinds of behavior, it is true that those would more frequently occur with persons having a co-occurring disorder than with a person solely having a psychiatric disability.

Moderator: Our chat is coming to a close and Dr. Kirk would like to make a concluding statement.

Dr. Thomas Kirk: In closing, I would like to congratulate the federal authorities for their leadership and raising awareness about the fact that substance abuse and mental illness are health care disorders and that they are highly treatable, and that as with any other serious health care disorder, people can learn to manage their illness and move onto the highest quality of life they can obtain. As Charles Curie, SAMHSA Administrator says, when all is said and done, what people in recovery from mental illness or substance abuse want, is what any of us want, and that is a decent place to live, something worthwhile to do, a social life. And so recovery month is helping to reinforce that theme and that vision. It is a message of hope, not one of despair.

Moderator: For more information about co-occurring disorders please visit SAMHSA's Mental Health Information Center at http://mentalhealth.samhsa.gov and SAMHSA's National Clearinghouse for Drug and Alcohol Information at http://ncadi.samhsa.gov.

Our hour has concluded. For more information, visit CSAT's Recovery Month Web Site at http://www.recoverymonth.gov. Visit the multimedia area (http://www.recoverymonth.gov/2003/multimedia/) to see a list of upcoming Web chats and Webcasts on various topics. You also can watch the archived version of the Webcast that complements this Web chat at http://www.recoverymonth.gov/2003/multimedia/w.aspx?ID=178.

We would like to thank our host, Dr. Thomas Kirk, from the State of Connecticut Department of Mental Health and Addiction Services for his participation in this online event, and thank our participants for their questions. This transcript will be available shortly so that others may benefit from the dialogue. The chat has now officially ended.