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New Yorkers Coping with Mental Health and Substance Use Conditions Find Hope Through Improved Care

Below are the stories of clients with co-occurring conditions whose lives have been transformed as a result of receiving integrated care, as well as stories of caseworkers from programs that have improved their delivery of care.

Clients
 

Cheryl*, a soft-spoken, 60-year-old grandmother, led a double life for years—as a respected secretary in the Office of the Mayor under three different administrations, and as a severe alcoholic whose addiction was fueled by undiagnosed mental illness. These conditions eventually led Cheryl to hit rock bottom. She lost her job and her family, and ended up homeless and living on the streets.

For many years, Cheryl worked in the seat of power at New York’s City Hall, as a secretary in the Office of the Mayor for Ed Koch, David Dinkins, and Rudolph Giuliani. She also was hiding a deep, dark secret—not about Gotham City’s tangled politics, but about herself.

“I drank myself to insanity,” said Cheryl, a soft-spoken, 60-year-old grandmother. “I went into work whenever I had to, but then it started catching up with me. Mondays were when I was always calling off. But by the grace of God I didn’t get fired…I guess because I was a good worker.”

But even a good worker like Cheryl could not pretend forever. The night that her daughter asked her to leave her apartment because of Cheryl’s raids on the liquor cabinet, she found herself homeless—and at rock bottom. “I went straight to the liquor store because I knew I was going to face the night on the street.”

There is a calmness as Cheryl speaks about her lowest point, knowing now that it has been two years and eight months since her last drink. She credits the growing realization that undiagnosed mental illness was fueling her alcoholism, as well as the focused approach to dealing with both problems when she sought treatment at the St. George MICA (Mentally Ill, Chemically Addicted) program operated by Richmond University Medical Center on Staten Island.

“Before I came here, I was really a person who really couldn’t talk—now I can,” said Cheryl, speaking of the anxieties and paranoid thoughts that drove her to the bottle. “Before…everything I harbored inside. Here, I feel free to talk.”

In 2008, the New York State Health Foundation established the Center for Excellence in Integrated Care (CEIC) initiative to help mental health and substance use programs across New York State make the necessary changes to address people’s mental health and substance use problems at the same time. The initiative was created in response to the widespread lack of integrated care for people struggling with both addiction and mental illness, which affects as many as 1.4 million New Yorkers. Studies have shown that as few as 10% of people with co-occurring conditions were receiving evidence-based treatment for both conditions, and that too many were falling victim to a wrong-door system of seeking treatment at a facility well equipped for one condition, but not the other.

By offering free evaluations and technical assistance, CEIC helped outpatient facilities across the State better integrate care for clients who have substance use disorders and also struggle with mental health issues. CEIC staff members conduct a thorough analysis and recommend program modifications and evidence-based techniques, such as improved intake screenings, and typically return to see how well their recommendations have been implemented. The ultimate goal of CEIC is to assist programs in helping clients, such as Cheryl, get the best possible treatment—clients who in the past were let down by incomplete care in earlier attempts for help.

In Cheryl’s case, neither she, her family, nor her co-workers realized that her heavy drinking was fueled by her undiagnosed mental illness, and that she was turning to alcohol as a way of coping with severe depression. “I started seeing things and I wouldn’t get out of bed, so my daughter stepped in and said, ‘You’re suffering from depression.’ I was tired. I couldn’t sleep, but I was going days without eating —just drinking. It was horrible.”

Like many clients, Cheryl spent a number of years in and out of treatment, bouncing from short stays in hospitals for psychiatric treatment or exhaustion to longer stays in residential alcoholism treatment centers. And also like many such clients, she suffered through a series of painful relapses, as these programs were good at treating parts of her complicated diagnosis, but largely overlooked other aspects.

At one facility on Staten Island, she said too many participants were still using drugs, and group sessions were unruly and unhelpful. “Then when I came here, they were more tough—they didn’t take no nonsense,” she said of the St. George program, which conducts regular tests of her urine to make sure she remains drug- and alcohol-free.

Today, she’s grateful for the holistic approach that she receives from the caseworkers at St. George MICA, including helping her find adequate housing near the facility, as well as encouraging her to get involved in groups and activities—some of them at the medical center—to get through the day without alcohol. Cheryl said that most weeks she comes to the program on Tuesdays and Thursdays. Some of her favorite discussions are on the topics of wellness and prevention—and understanding what used to trigger her drinking binges. “They make sure that we get at least five to twenty minutes,” she said of the discussion groups, “but if I come in a little excited, they let me talk more.”

The success of the St. George MICA program is no accident. In addition to a dedicated staff, the Staten Island facility has benefitted greatly from its work with CEIC as one of more than 600 facilities across New York State that CEIC evaluators have assessed and then advised on the most successful practices for treating patients with co-occurring conditions of mental illness and addiction. CEIC staff members looked at everything—from whether the waiting room offered pamphlets on the relationship between mental health and substance use to whether the intake screening questionnaires asked the best questions to get the correct diagnosis.

Cheryl said that the counselors at St. George MICA were skilled in gaining her trust. “During the course of our conversation, she had asked me if I had had a drink—I said, ‘You could do my urine.’ She said, ‘Can I go by your word,’ and I said, ‘You can never ask an alcoholic that.’” However, she now beams at the fact that she has not had a drink for so long, is living in her own place, and is slowly working at repairing her relations with her family.

“I lived like a dog,” she said, speaking of her decades-long battle with alcohol. “Worse than a dog…. dogs have homes.”

Christopher* can recount his odyssey through the military, the many jobs, the failed marriage, the drug use, and the occasional interludes in Brooklyn psychiatric wards in excruciating detail—jumping back and forth rapidly between the stories, and between the years. Only recently did doctors discover that his years of substance use were closely tied to a diagnosis of bipolar disorder.

“I was going in and out of psych hospitals.” said Christopher, a balding, compact 55-year-old man whose words are drenched in a thick Brooklyn accent. “I had different jobs—I worked for my mother in a sweatshop, I worked as a short-order cook, my last job I had working at the Key Food warehouse where I was a picker and I used to collect different kind of groceries from the warehouse and put the skids onto the truck to go to the stores.”

As Christopher bounced from drug treatment programs to hospital emergency rooms, it took years for clinicians to understand that the significance of his story was not just in the details—but in the frenzied, rushed, and jumbled way that he delivered it. Only recently did doctors discover that his years of substance use were closely tied to a diagnosis of bipolar disorder, also known as manic depression.

The better diagnosis of Christopher’s condition has led to a new mix of medications that have smoothed over his frequent ups and downs. Now, he says, he has gone nearly two years without using drugs, and he gives a lot of credit to the counselors and treatment at the St. George MICA (Mentally Ill, Chemically Addicted) program run by the Richmond University Medical Center on Staten Island, the borough where he now lives. He said he looks forward to twice-a-week group sessions there.

“We talk about how we feel, we talk about ourselves, our diagnosis, and who our therapist is and our medications,” said Christopher, who sounded delighted to have found other people who understand his travails and what he has been through. “We discuss everything about ourselves."

Christopher said that he started taking drug treatment more seriously about five years ago because he had to. A judge ordered that he undergo drug treatment after he hit rock bottom and got into a domestic altercation with his girlfriend in which he said he was so drunk he did not remember striking her. Eventually, he said, the court mandate was lifted, but by then he had heard positive things about the St. George MICA program and decided to enroll voluntarily. Now, he says, he wouldn’t think of giving up the structure that the program provides him. “I don’t have to be in this program—I just come,” he said. “It gets me clean.”

The St. George MICA program where Christopher is receiving treatment has been fine-tuned to identify and help people like him, who have what clinicians call the co-occurring conditions of mental illness and addiction. It is one of more than 600 facilities that has received help in improving care for clients with co-occurring conditions from the Center for Excellence in Integrated Care (CEIC)—an initiative funded by the New York State Health Foundation.

Established in 2008, CEIC offers free evaluations and technical assistance to mental health and substance use programs across New York State to help them make the necessary changes to address people’s mental health and substance use problems at the same time. CEIC was created in response to the widespread lack of integrated care for people struggling with both addiction and mental illness, which affects as many as 1.4 million New Yorkers. Studies have shown that as few as 10% of people with co-occurring conditions were receiving evidence-based treatment for both conditions, and that too many of them were falling victim to a wrong-door system of seeking treatment at a facility well equipped for one condition, but not the other.

CEIC staff members conduct a thorough analysis and recommend program modifications and evidence-based techniques, such as improved intake screenings, and then typically return to see how well their recommendations have been implemented. The ultimate goal of CEIC is to assist programs in helping clients, such as Christopher, get the best possible treatment—an outcome that has often eluded them in earlier effort to get help.

Christopher had been struggling with his drug and alcohol problem for a long time. He said he started drinking when he was 12 years old, first tried marijuana when he was 15 years old, and soon started using drugs regularly. In fact, he says he got into trouble stationed in the Navy in California, when he was caught with marijuana. Soon he was discharged and back in New York City during the 1980s, an era when the streets were awash in crack cocaine.

“I had a nervous breakdown,” he said, recalling how the doctors at one hospital gave him a cocktail of antipsychotic drugs. “I thought people were after me. I was very paranoid. I assumed it was the drugs—the cocaine made me paranoid, and I used to smoke pot and cocaine and drink.”

In hindsight, Christopher was let down by the prevailing ways of treatment delivery at that time, when there were silos in which clients were sent to programs that specialized in drug treatment or to mental health facilities, but few facilities offered truly integrated care for both conditions. He underwent lengthy stays at various New York hospitals and a Veterans Affairs facility, and later spent time in a residential drug treatment program in the Bronx. He said he tried group therapy early on, but he was not ready for it. “I didn’t take it seriously,” he said, while psychiatrists prescribed him drugs, but did little else for him.

Even after he moved to Staten Island and began seeking treatment at St. George MICA, Christopher suffered a relapse about two years into the program, when he discovered other people using marijuana at a party and was unable to resist. “I smelled it in the air—I was glorifying it and I bought a joint and I smoked it and they caught me in a urine test,” he said.

Dealing with relapses is a frequent issue for a drug treatment clinic—and arguably the most difficult. Some rigid, boot-camp-like programs have a no-tolerance policy, and Christopher said if the relapse had occurred while he was under the court mandate, he would have been sent to jail. Instead, he talked through the incident with his counselor, refocused his therapy, and has been clean for nearly two years now.

Christopher gives a lot of credit to the relapse prevention group that he joined at the St. George clinic after that incident. “We care about ourselves,” he said.

Danielle* Just 24 years old, vivacious, and well spoken, Danielle said she is typically greeted with shock when she tells new college friends that she is a recovering drug addict, still undergoing outpatient treatment at a nearby clinic on Staten Island.   

“One of my close friends that I just made says I can’t imagine you having an addiction problem,” Danielle said. “I can’t imagine you being high, or drunk, or all these other things and it’s just so funny because he’s one of the only people who’s never seen me like that, and it’s refreshing. I love it.”

Indeed, if you meet Danielle today, you would never know that when she arrived at the St. George MICA (Mentally Ill, Chemically Addicted) program on the north shore of Staten Island, she had been smoking so much marijuana that it took 90 days to test out of her system. Just a couple of years ago, the young woman, who is now studying creative writing at the College of Staten Island, was popping pills, taking the drug Ecstasy, drinking, and smoking pot, and frequently got into physical altercations.

It took a long time—and various efforts at treatment and counseling, including years of therapy, physician care, and a stay at another private inpatient facility—to get to the root of Danielle’s problems. But staff members at St. George MICA, which is run by the Richmond University Medical Center, took a more holistic approach to her addiction struggles, and that made a difference.

The Staten Island facility is one of hundreds across New York State to receive evaluations and technical assistance from the Center for Excellence in Integrated Care (CEIC)—an initiative funded by the New York State Health Foundation. The goal is to dramatically improve treatment for New Yorkers, such as Danielle, who suffer from co-occurring conditions of mental illness and substance use—and in her case, the effort really paid off. Thanks to an aggressive intake screening and consultation with a psychiatrist, the St. George program determined that Danielle’s drug use was related to bipolar disorder, also known as manic depression.

“They asked me all these questions and they determined I was bipolar and I was being misdiagnosed for so many years. I was taking depression medicine for the depression, but it didn’t help the racing thoughts. That’s why I was smoking marijuana—at the time I didn’t realize it was to slow down my brain.” With her new diagnosis, Danielle changed her medication, and she has been able to stay drug- and alcohol-free for the past year.

Established in 2008, CEIC was created in response to the widespread lack of integrated care for people struggling with both addiction and mental illness, which affects as many as 1.4 million New Yorkers. Studies have shown that as few as 10% of people with co-occurring conditions were receiving evidence-based treatment for both conditions, and that too many were falling victim to a wrong-door system of seeking treatment at a facility well equipped for one condition, but not the other.

By offering free evaluations and technical assistance, CEIC helped outpatient facilities across the State better integrate care for patients who have substance use disorders and also struggle with mental health issues. CEIC staff members conduct a thorough analysis and recommend program modifications and evidence-based techniques, such as improved intake screenings, and typically return to see how well their recommendations have been implemented. The ultimate goal of CEIC is to assist programs in helping clients, such as Danielle, get the best possible treatment—clients who in the past were let down by incomplete care in earlier attempts to seek help.

On Staten Island, Danielle said she has been crying out for help since she took her first drink of vodka in the 7th grade. Initially, she thought pills and alcohol were an escape path from a terrible situation at home, where her father was abusive and also had a drinking problem. Eventually, she moved from marijuana to Ecstasy and pills, which were widely available. “I have no idea what they even are—people were using colors, and I have no idea what they mean.”

Danielle’s mental health problems were exacerbated by her use of drugs, including psychedelics. But as a teen, the doctors and psychologists who she saw treated her for conventional depression. She said she was aware of her racing thoughts, but had no idea they were a symptom of more severe mental illness.

Eventually, Danielle volunteered that she thought her problems were more serious, but she said no one listened—until she was referred to St. George MICA. “Not until I got here did they listen to me and understand that I have depression, but I also have the manic part of bipolar disorder,” she said.

Doctors affiliated with the Staten Island program changed her medication regimen, but like many struggling with addiction, Danielle wasn’t cured overnight. Indeed, she suffered a relapse several months after her arrival at St. George MICA when she told herself it was okay to try some marijuana—derailing her recovery for a time. CEIC provides programs with recommendations on how to handle relapses by clients with co-occurring conditions, a frequent problem that requires tolerance, but not too much.

Danielle said that her counselor at St. George has been able to walk the line between toughness and empathy. “That’s what I need, someone who will tell me the truth,” she said. “I didn’t need someone who’s going to tiptoe around messes. She’s not nasty about it in any way—she’s just truthful.”

Now, Danielle is practically giddy as she discusses her newfound sobriety, even as she reflects on the annual nationwide marijuana festivities held on April 20.

“I celebrated April 20th every year as a glorious holiday—and it was just a means to do a bunch of pot, just a bull---- cop-out excuse,” she said.  “Now, I go out to eat with my Mom. It’s a new day to celebrate. It’s like replacing that negative with the positive, in a way.”

Jerome* For Jerome, the road to recovery has been littered with false starts and missed opportunities. Now 39, the barrel-chested Long Island native with a soft, gentle voice calmly narrates, in remarkably rich detail, his more than two-decade-long odyssey through drugs and depression that started with smoking pot with high school buddies at the duck pond behind Freeport High School and ended with binges of crack cocaine, with stays in Nassau County psychiatric wards and homelessness on the streets in between.

It’s not that Jerome didn’t receive help during those lost years. In fact, he went through a variety of treatments and interventions, but nothing seemed to really stick. His experiences ranged from a drug-treatment house that operated like a Marine boot camp to hospitalizations where he received large doses of antipsychotic drugs. Like the parable about the blind man and the elephant, no one seemed to grasp the whole picture.

Every intervention ended with Jerome walking away. “At that point my way of thinking was, I don’t have kids,” he said, recalling his state of mind around the time he hit 30. “Who am I hurting? I’m not hurting anybody but myself, not realizing that you really are hurting yourself. At that point, you’re not looking at it like that.  I’m trying to rationalize using…”

In 2009, there were two breakthroughs for Jerome. First, a psychiatrist diagnosed his psychological condition as a severe form of bipolar disorder with psychotic tendencies, and he prescribed Jerome new, targeted medication. A short time later, Jerome was referred to South Shore Child Guidance Center (South Shore), a small counseling center that began helping young children of substance users, but has gradually expanded its programs to focus more on adults—especially on clients, such as Jerome, struggling with both addiction and mental illness.

In 2008, the New York State Health Foundation established the Center for Excellence in Integrated Care (CEIC) initiative to help mental health and substance use programs across New York State, including as South Shore, make the necessary changes to address people’s mental health and substance use problems at the same time. The program was created in response to the widespread lack of integrated care for people struggling with both addiction and mental illness, which affects as many as 1.4 million New Yorkers. Studies have shown that as few as 10% of people with co-occurring conditions were receiving evidence-based treatment for both conditions, and that too many were falling victim to a wrong-door system of seeking treatment at a facility well equipped for one condition, but not the other.

By offering free evaluations and technical assistance, CEIC helped outpatient facilities across the State better integrate care for clients who have substance use disorders and also struggle with mental health issues. CEIC staff members conduct a thorough analysis and recommend program modifications and evidence-based techniques, such as improved intake screenings, and typically return to see how well their recommendations have been implemented. The ultimate goal of CEIC is to assist programs in helping clients, such as Jerome, get the best possible treatment—clients who in the past were let down by incomplete care in earlier attempts to seek help.

“I had nothing from nothing—but throughout all that the counselors helped me to get what I had to get, and I learned how to advocate for myself,” Jerome said, adding that, now: “I talk. Whatever bothers me during the week, on Saturday I come here and let it out, and then I start back over again.”

And Jerome is a man with a lot to say. He can trace the long downward spiral of his young adulthood in excruciating detail. He never really knew his own dad, and when his mother moved on to have another son and two daughters with a different father, Jerome said he felt like the black sheep of the family during a youthful period of heavy drug use and occasionally dealing crack cocaine.

His one anchor was a close relationship with his younger half-brother Anthony. “He was the one I could go to who didn’t judge me,” said Jerome. So when Anthony was shot and killed during a squabble with extended family members on a February night in 1997 that Jerome will never forget, his world really began to fall apart.

“The day it happened, and for a long period of time, I blocked it out… I didn’t feel,” Jerome recalled. “I didn’t cry. I was just lost because that was the one person I had that I confided in, that I talked to, that I had that could really get through to me.” Soon after, Jerome said he was selling crack again and using cocaine heavily.

Jerome had his first intervention while in his mid-20s in 2000—an extended stay at one of Long Island’s better-established residential drug treatment facilities, a highly regimented place where clients were assigned frequent chores and had to constantly report their whereabouts. “I left the program—it wasn’t for me,” Jerome recalled. “It was all about house meetings and this, that, and the other…I needed more one on one.”

Jerome said that a second stay at a different Long Island residential treatment facility about five years later was initially more successful—he says he was off drugs for about two years—but foundered after a haphazard effort to find him reliable permanent housing. “I wound up back in a house where they were smoking crack,” he said.

By this time period—the second half of the 2000s—Jerome was having more and more episodes that resulted in trips to the psychiatric ward. In 2005, when a treatment intake officer asked Jerome pointed questions about whether he intended to harm himself or had access to guns (“I don’t have any, but I know where I could get them,” he replied), police rushed him to the psychiatric unit of a hospital in Nassau County, and he stayed there for eight days. Psychiatrists tried an array of antidepressants and antipsychotics medications, but nothing worked—in part because of his ongoing addiction to recreational drugs.

When Jerome first came to South Shore, he was destitute and recently arrested for shoplifting. “I came in here beat up…I didn’t feel like I was going to get help,” he recalled. “I kept thinking I’m not going to be here long. I didn’t have any clothes. I was really at rock bottom.”

Jerome’s turnaround was helped by the better diagnosis of his bipolar condition, which led to a successful switch in his medications. But he gives a lot of credit to the counselors at South Shore, who made themselves available to deal with problems around the clock and—working with a psychiatrist, who checks in on Jerome once a month—developed a more holistic approach to his many issues, including finding housing and work.

Both Jerome and his counselors also commend the group therapy sessions for clients with co-occurring disorders—a place where clients can share their unique struggles against the mental illness that has fed their addictions. Those groups were added and fine-tuned with input from the CEIC evaluators.

Today, Jerome, who collects disability payments, lives in his own apartment in Freeport and finds part-time work while he looks for a full-time job in a still-sluggish economy. Drug-free, he comes to South Shore every Saturday for one-on-one counseling and therapy, but he said the program is offering him so much more.

“I don’t have to wait until Saturday—that’s why I love this place,” he said. “If I called up and said, ‘Listen can you squeeze me in, I need you,’ they don’t turn me away. If there’s anything I need, they don’t hesitate to help me and I can’t ask for more than that.”

Nicole* You would never know from talking with Nicole*, now a doting grandmother at age 57, that she had spent most of her adult life battling heroin addiction. “I’m actually into life now,” said Nicole, speaking from the drug and mental health program on the north shore of Staten Island where she has been receiving regular treatment and counseling for the past five years. “I’ve got a granddaughter that I’m really into—I’ve only got one, so I’m focused on her…I thought I needed drugs to cope and get along.”

Nicole first started seeking help for substance use, depression, and related issues about four decades ago—but for most of that time, nothing clicked. She says in hindsight that there were two roadblocks to getting help.

First, neither Nicole nor her many doctors or counselors seemed to grasp that her devastating bouts with depression were not occasional episodes, but a chronic, recurring problem that required more aggressive treatment. “At that time, early on, it was like, ‘OK, you’re depressed,’ and I’m thinking depression meant you’re depressed for a little while and then it goes away,” she recalled. “Since I’ve been here in Staten Island, I’ve learned it was not necessarily that way, but [depression is] something you have to take care of on a regular basis.”

Second, Nicole said she found that other drug treatment programs she had been sent to were highly regimented places—but their efforts to impose order and strict discipline only served to drive her away and back out into the streets. “Other programs were more intense—a lot more strict and a lot less personable,” she said. “Sometimes that hardcore treatment might work, but it doesn’t work for a lot of people. I need to know that this person actually cares about me, is concerned about me.”

The lifelong New Yorker said that when she first started receiving therapy and medical treatment from the St. George MICA (Mentally Ill, Chemically Addicted) program on Staten Island five years ago, she finally felt that she was at home. The program is a unit of Richmond University Medical Center that has thrived in an unlikely setting, an old Depression-era hospital on a hillside overlooking Lower Manhattan. It is one of 600 such facilities across New York State that has been evaluated by the Center for Excellence in Integrated Care (CEIC)—an initiative funded by the New York State Health Foundation. CEIC worked with St. George MICA to help the program better integrate care to help clients, such as Nicole, with their co-occurring conditions of substance use and mental health disorders.

“They care about you here—enough that you don’t want to disappoint anybody,” said Nicole of her renewed sense of purpose that has allowed her to stay drug free in the program, where she has received both one-on-one counseling and attended group sessions as often as five days a week.

Established in 2008, CEIC offers free evaluations and technical assistance to substance use and mental health outpatient facilities across the State to help them make the necessary changes to address people’s mental health and substance use problems at the same time. CEIC was created in response to the widespread lack of integrated care for people struggling with both addiction and mental illness, which affects as many as 1.4 million New Yorkers. Studies have shown that as few as 10% of people with co-occurring conditions were receiving evidence-based treatment for both conditions, and that too many of them were falling victim to a wrong-door system of seeking treatment at a facility well equipped for one condition, but not the other.

CEIC staff members conduct a thorough analysis of facilities and recommend program modifications and evidence-based techniques, such as improved intake screenings, and typically return to see how well their recommendations have been implemented. The ultimate goal of CEIC is to assist programs in helping clients, such as Nicole, get the best possible treatment—an outcome that has often eluded them in earlier effort to get help.

Nicole said she came of age at the end of 1960s, when heroin flooded the streets of New York. But she said her mental strains, and her first youthful turn toward drugs, were motivated by something more personal—childhood sexual abuse.

“I was going through problems, there were some things in my mind I couldn’t control,” she recalls. “I was a victim—a victim of child molestation by my father. I was at the age where I wanted to tell my peers. I wanted to talk about it…but you couldn’t. I didn’t realize what it was doing until I got much older and into therapy.”

Ultimately, she said she used drugs as an escape for decades, even as she raised her two children. She went through several attempts at drug treatment, but typically her struggles with depression were seen as a symptom, and not the core, of her problems. One of the strengths of the St. George MICA program has been regular consultations with a psychiatrist who has been able to adjust her medications to help her finally manage her depression. That, in turn, has helped give her the strength to stay away from drugs—this time, she hopes, for good.

“When depression weighed so heavily, I couldn’t function—but that hasn’t happened since I’ve been here,” Nicole said, who added that her moods have been leveled out by a better medication regimen. But that is not the only reason she has stayed with the program at St. George. She said the counselors have been flexible and willing to meet with her two or three times a week if she is experiencing extra stress in her life.

She said that it took some time for her to feel comfortable talking about herself in group therapy sessions, but it has become a key part of the program for her. Nicole said she and other recovering addicts now share how long they have been away from drugs, or fighting occasional triggers of going back to use. “Everybody has the time [to talk],” she said.

Since it has been difficult for Nicole to find full-time work—a common problem for people recovering from substance use in the sluggish New York economy—the programs offered at St. George MICA have given her one other important thing, which is structure. Between her visits to the clinic and working as the primary caretaker for her granddaughter, she feels that she has a full life that she can enjoy without the physical toll that drugs were once taking on her body.

“I feel a great sense of freedom,” she said.

Simone* always blamed her long slide into drug addiction on the fact that she was rebelling against her very strict upbringing by her Palestinian-born parents. It was not until a couple of years ago that the native Long Islander was diagnosed with bipolar disorder—and understood its relationship with her substance use.

“If I didn’t have my mental illness, I don’t think I would have done the things that I did,” said Simone, now 34, at the South Shore Child Guidance Center (South Shore), the outpatient program where she receives treatment in her current hometown of Freeport. “I don’t think a person with the right frame of mind would do the things that they do, and make the choices they make.”

For Simone, those choices included years of alcohol use, marijuana smoking, and cocaine use that led to a two-and-a-half month binge on crack cocaine before she bottomed out.  In animated tones, she described the last straw: “Losing my apartment and being homeless, and not having nowhere to turn to and nowhere to go, and feeling like I didn’t have a soul in my body and like I wasn’t just worth anything."

After a week in a hospital, Simone began regular therapy three years ago at South Shore. It happened to be at the same time that South Shore began working with the Center for Excellence in Integrated Care (CEIC) to enhance its programs. The South Shore center and its energetic founder, Mary Lou Jones, are widely respected in Long Island’s western suburbs for their longstanding work with children and families of substance users, but as the center offered more programs targeting adults—now 70% of its caseload—CEIC found there was room for more improvement.

In 2008, the New York State Health Foundation established the CEIC initiative to help mental health and substance use programs across New York State, including South Shore, make the necessary changes to address people’s mental health and substance use problems at the same time. The program was created in response to the widespread lack of integrated care for people struggling with both addiction and mental illness, which affects as many as 1.4 million New Yorkers. Studies have shown that as few as 10% of people with these co-occurring conditions were receiving evidence-based treatment for both conditions, and that too many were falling victim to a wrong-door system of seeking treatment at a facility well equipped for one condition, but not the other.

By offering free evaluations and technical assistance, CEIC helped outpatient facilities across the State better integrate care for clients who have substance use disorders and also struggle with mental health issues. CEIC staff members conduct a thorough analysis and recommend program modifications and evidence-based techniques, such as improved intake screenings, and typically return to see how well their recommendations have been implemented. The ultimate goal of CEIC is to assist programs in helping clients, such as Simone, get the best possible treatment—clients who in the past were let down by incomplete care in earlier attempts to seek help.

Robert Sabino, a 41-year-old caseworker who has been at South Shore for about a dozen years, said that some of the recommendations made by CEIC might be characterized as tweaks to the program —updating the clinic’s mission statement to include its newfound emphasis on treating clients with co-occurring conditions, and making sure that literature about common mental health problems, such as anxiety or depression, are scattered about the waiting room so new clients who walk in can think about possible connections.

But other changes that came about as a direct consequence of CEIC’s initial evaluation, Sabino noted, were more substantive. Most importantly, the center updated its intake evaluations to probe more extensively for evidence of mental illness and psychological disorders.

There were also changes in the way that group therapy was offered at South Shore—to increase client education and film offerings on mental health issues, and to give more clients greater opportunities to talk more often about their co-occurring conditions in group sessions with their peers who shared similar problems. In some individual cases, Sabino said, the improved outcomes were striking.

Sabino recalled a male client in his 40s who came in for substance use treatment, but disappeared from the program after a while and went back to using drugs. He showed up a second time, months later, and was given the new recommended screening—and scored high on a scale that measured for mental illness. “The first time he came through here, it was completely missed, but there was a benefit to adding the screening,” Sabino said. “The second time, we ended up putting him on medication."

In a follow-up evaluation two years later, CEIC found that South Shore had made great strides in improving the integration of care for its clients.

As for Simone, she said she reaped the benefits of a program that had been retooled to focus on clients like herself, who only recently had learned that their psychiatric condition was a major factor behind years of addiction. She said the group sessions run by her counselor at South Shore, Kara Lee Walsh, as well as her one-on-one sessions, have been critical in understanding what triggered her years of drug use.

“I’ve been to a lot of places that offered therapy and this is the only place that I like —really, they go all out for you, they really do.”

For years, Simone faulted her family situation as the source of her problems. She said that while growing up in the Long Island community of Long Beach, her Middle Eastern parents imposed much stricter rules than other parents about going out to movies or to the mall, and also insisted she spend time with her younger brother and sister instead of friends.

“I always felt I was trapped—they just wanted us to be home and I just wanted to do the opposite of what they wanted to do, regardless of whatever it was,” Simone recalled. She rebelled—getting arrested for shoplifting and using drugs more and more frequently. By the time she hit her 20s, working as a clerk at a clothing store chain, she saw her friends from high school get married and have children, while she said she was unable to quit partying.

Simone is still wracked with guilt over her younger brother’s suicide several years ago. “I blamed myself for that for a long time because I was not a good example to him,” she said, noting it was not until her counseling sessions with Walsh at South Shore that she came to accept her brother’s death was not her fault.

During her three years as an outpatient at South Shore, Simone says that she has been able to stay completely off drugs while moving from a recovery house to her own apartment in Freeport. She said she now works a couple days a week in a nearby Laundromat while she continues to look for full-time work. She brightens up the most, though, when she talks about how therapy at South Shore has helped to repair her relationship with her mother.

She said her South Shore counselors told her: “‘Love your mom from a distance, you got to remember, Simone, that she is who she is and she grew up different from you and you got to respect that.’” Today, she said the thought of her parents and everything they have been through with her is a prime motivator to stay away from drugs.

“That’s one thing that keeps me straight,” she said. “I wouldn’t want to disappoint them because I put them through so much.”

*Name changed to protect patient’s privacy

Caseworkers


Ileana Acosta has led at-risk teens on rugged canoe trips through the swampy wilderness of Florida and counseled parents of substance users at the acclaimed Harlem Children’s Zone program, before finally settling down to work at a conventional mental health clinic on Staten Island.

Her early endeavors convinced her that her true calling in life is to work with adults with the dual—or co-occurring—conditions of addiction and mental illness. And so she calls her current job at the St. George MICA (Mentally Ill, Chemically Addicted) program, run by Richmond University Medical Center, “a match made in heaven.”

“I think we’re doing a great job here—right down to the system we use on the computer,” said Acosta, who speaks with the youthful enthusiasm of a woman who genuinely loves her position. She has only been at St. George MICA for about 13 months, but she said the program was constantly fine-tuning and upgrading its intake procedures and its clinical practices to stay on top of the growing body of knowledge on treating clients with co-occurring conditions.

St. George MICA is one of more than 600 facilities that has received help in improving integrated care for clients with co-occurring conditions from the Center for Excellence in Integrated Care (CEIC)—an initiative funded by the New York State Health Foundation.

Established in 2008, CEIC offered free evaluations and technical assistance to mental health and substance use programs across New York State to help them make the necessary changes to address people’s mental health and substance use problems at the same time. CEIC was created in response to the widespread lack of integrated care for people struggling with both addiction and mental illness, which affects as many as 1.4 million New Yorkers. Studies have shown that as few as 10% of people with co-occurring conditions were receiving evidence-based treatment for both conditions, and that too many of them were falling victim to a wrong-door system of seeking treatment at a facility well equipped for one condition, but not the other.

CEIC staff members conduct a thorough analysis and recommend program modifications and evidence-based techniques, such as improved intake screenings, and typically return to see how well their recommendations have been implemented. The ultimate goal of CEIC is to help dedicated caseworkers, such as Acosta, provide the best possible treatment for their clients—many of whom were let down by incomplete care in earlier attempts for help.

CEIC staff members gave the St. George MICA program solid ratings for its integrated care of clients—a testament to the program’s hard-working staff members. While the building itself is somewhat old—it was built during the New Deal of Franklin Roosevelt’s presidency in the 1930s—on the inside, the program’s directors and clinicians use 21st-century diagnostic tools to treat patients. Acosta said one recent upgrade that has been particularly invaluable is a computer program called Psych-Ease, which offers her and her co-workers not only a complete record of a client’s recent medical treatments, but also which prescriptions have been filled—or have not. “Before we had to give them the benefit of the doubt of whether they were telling the truth…or whether they were in denial, or just had a bad memory,” she said.

Acosta said she developed her passion for treating clients with co-occurring conditions through a process of trial and error. Her adventure of taking teenagers on two-week canoeing expeditions in the swamp for the organization Outward Bound convinced her that she would rather be working with adults. “I watch the show 'Survivor,' and I think of my experiences,” she said. That job was a break between her studies in forensic psychology at John Jay College of Criminal Justice and graduate work in counseling at New York University. She initially gravitated toward mental health treatment, but during her time at the Harlem Children’s Zone program, much of her work was counseling parents whose children were hooked on drugs.

Indeed, she finds that her academic background in forensics helps her find the connections between substance use and mental illness that her clients may be unaware of. “Mental illness sometimes leads a person to do drugs and sometimes people don’t really realize,” she said. “A lot of times I get the reaction, they’ll say, ‘You’re right, come to think of it, when I do use marijuana I do get somewhat paranoid,’ and, ‘When I use marijuana I do tend to get into these periods of depression,’ and it just brings them more to their awareness. It helps us help them, to really focus on the importance of recovery.”

Acosta believes that her relative youth is a big asset, and that it helps her relate to young clients in the Staten Island program. “They think of an older person with glasses, taking notes,” she said, invoking images of Sigmund Freud. Although she uses a variety of therapeutic approaches in her one-on-one sessions with clients, such as cognitive behavioral therapy, she says the goal is frequently to encourage them to find healthy responses to the events and moods that trigger their substance use.

“We also provide them with what these alternatives might be—exercising or engaging in a fellowship meeting, coming to a program or just establishing a sober support system, identifying what your interests might be that aren’t being paid attention to because you’re too busy getting high,” Acosta explained.

She said that in her short time at the St. George MICA program, CEIC’s recommendations have been particularly helpful, and that the overall treatment plan is tweaked and updated roughly every three months. She said the real asset of the program in dealing with the complex, overlapping issues of patients with co-occurring conditions is its flexibility in handling relapses, which might lead to immediate dismissal from other programs.

“If someone comes in who’s had an issue with drug use, we assign them to programs right away,” she said. “It’s not lackadaisical.”

Kathleen Boatswain has spent decades as a mental health caseworker in New York City. In the hard economy of the 1990s, she worked with clients in Brooklyn’s most poverty-plagued neighborhoods. She then sought to soothe her clients’ souls in the smoldering aftermath of the terror attacks of September 11, 2001. But some of the most satisfying years of her long career have been spent the last 12 at the St. George MICA (Mentally Ill, Chemically Addicted) program on the northern shore of Staten Island, where she has been counseling clients who deal with both mental health and substance use issues.

“I worked in the ‘70s and ‘80s and ‘90s in mental health,” said Boatswain, who remarked that her extensive work in the field has shown her the ways that addiction frequently overlaps—and has prepared her well for the caseload at St. George. “I kind of feel I have more knowledge, and I think more recognition, that substance abuse is a factor.”

Too often in the past, a skilled clinician like Boatswain would have been working in a silo at a mental health clinic, where addiction services were an afterthought. But the St. George MICA program—a unit of the Richmond University Medical Center—has spent much of the last decade rethinking how drug dependency and mental health treatment interact so it can offer new services and make the most of talented caseworkers, such as Boatswain.

For example, the program’s director, Michael Matthews, said that mental health clients who have successfully stayed off drugs or alcohol for a while—the type of client who historically might disappear from some addiction programs, and then suffer a relapse—are placed in a newly created program called MICA Recovery and are monitored closely. Many of the candidates for that program, Matthews explained, are identified through an improved screening process.

“We’re doing this so we can identify patients and put them with therapists,” Matthews said. “We changed the intake process so that anyone who comes for an evaluation and a referral who reports a substance-abuse history, but denied current use…in the past they would go to straight mental health, [but] now they go to MICA Recovery."

St. George MICA is one of more than 600 facilities that has received help in improving integrated care for clients with co-occurring conditions from the Center for Excellence in Integrated Care (CEIC)—an initiative funded by the New York State Health Foundation.

Established in 2008, CEIC offerrd free evaluations and technical assistance to mental health and substance use programs across New York State to help them make the necessary changes to address people’s mental health and substance use problems at the same time. CEIC was created in response to the widespread lack of integrated care for people struggling with both addiction and mental illness, which affects as many as 1.4 million New Yorkers. Studies have shown that as few as 10% of people with co-occurring conditions were receiving evidence-based treatment for both conditions, and that too many of them were falling victim to a wrong-door system of seeking treatment at a facility well equipped for one condition, but not the other.

CEIC staff members conduct a thorough analysis and recommend program modifications and evidence-based techniques, such as improved intake screenings, and typically return to see how well their recommendations have been implemented. The ultimate goal of CEIC is to help dedicated caseworkers, such as Boatswain, provide the best possible treatment for their clients—many of whom were let down by incomplete care in earlier attempts to seek help.

In one respect, the St. George program is certainly different from some of the other programs that CEIC has worked with in New York State, because it has such extensive experience with the concept of treating clients with co-occurring conditions. Boatswain noted that has been the goal of the program ever since she arrived in 2001; the major changes she has noted over those years have been adjustments to better identify which clients are coping with both mental health and substance use problems.

Boatswain said that she had already worked in the mental health field for decades before she earned her master’s degree in psychotherapy in 1990. Three years later, she began working in a mental health clinic that was part of an effort to revitalize East New York, an economically distressed section of Brooklyn. It was that experience that showed her how many of her mental health clients were struggling with drugs or alcohol.

After she arrived at St. George MICA on Staten Island, Boatswain said she had more of an opportunity to use techniques, such as motivational therapy or cognitive behavior therapy, with the goal of changing clients’ addictive behaviors. She currently runs two group sessions—one for women and the other for any clients with co-occurring disorders— and says that she urges the clients with co-occurring disorders to share their experiences with one another.

“Just basically, especially in the groups I’m looking at how the clients interact with one another and certainly encouraging more interaction among the clients and getting clients to feed back to one another, as opposed to having it all come from me,” Boatswain explained. “That’s because a lot of the clients have been involved in therapy for a while and know especially with drugs and alcohol—they know about AA (Alcoholics Anonymous), they know about staying away from people, places, and things. Just letting clients feed that information to one another is more important in the groups, as opposed to having it all come from me. I think it’s better received.”

The administrators of the St. George program said its fairly positive CEIC evaluations are not only the result of using highly experienced counselors, such as Boatswain, but also by relying on upgraded technology, including the latest intake software to eliminate factors, such as human error or client dishonesty, that have led to the wrong classification of clients in the past.

“You’re not just taking the client right at face value,” said Elissa Donner, a MICA specialist, of the improved computerized tracking of patients. “You can’t do that anymore, you can’t! You have to have a different type of screening or assessment with them now and a different type of interviewing, which a lot of the mental health clinicians got educated on.”

Robert Sabino, a caseworker who works with substance use clients at the South Shore Child Guidance Center on Long Island, is the kind of dedicated worker who thinks a lot about the one who almost got away. Sabino remembers a male client in his 40s who came into the Freeport clinic seeking treatment and aid for drug addiction, but then the man disappeared from the program after a while and went back to the street. Fortunately, Sabino recalled, the man reappeared a second time, months later.

This time, the client went through a completely different intake screening—one that was recommended by a team of outside advisors who had recently reviewed the South Shore facility from top to bottom, with the goal of improving its treatment of clients with the co-occurring conditions of substance use and mental health disorders.

The new intake procedure showed that Sabino’s client was indeed suffering from a form of mental illness that had not been addressed earlier. “The first time he came through here, it was completely missed—but there was a benefit to adding the screening,” Sabino said. “The second time we ended up putting him on medication,” said Sabino, which addressed his underlying mental health problem and helped the South Shore staff to better focus on his drug addiction.

That type of success story is exactly the aim of the Center for Excellence in Integrated Care (CEIC)—an initiative funded by the New York State Health Foundation to address gaps in treatment for people who suffer from mental illness and are also addicted to drugs or alcohol. It is a problem that has long frustrated workers, such as Sabino, who are trying to help clients struggling with both conditions. The idea behind CEIC is to give them tools and best practices to make their efforts more successful.

Established in 2008, CEIC offers free evaluations and technical assistance to mental health and substance use programs across New York State to help them make the necessary changes to address people’s mental health and substance use problems at the same time. CEIC was created in response to the widespread lack of integrated care for people struggling with both addiction and mental illness, which affects as many as 1.4 million New Yorkers. Studies have shown that as few as 10% of patients with these co-occurring conditions were receiving evidence-based treatment for both conditions, and that too many of them were falling victim to a wrong-door system of seeking treatment at a facility well equipped for one condition, but not the other.

CEIC staff members conduct a thorough analysis and recommend program modifications and evidence-based techniques, such as improved intake screenings, and typically return to see how well their recommendations have been implemented. The ultimate goal of CEIC is to help programs and their caseworkers, such as Sabino, provide the best possible treatment for clients who in the past were let down by incomplete care in earlier attempts to seek help.

In the case of the South Shore facility, the recommendations from CEIC are helping the clinic—located on a busy commercial strip in a heavily populated section of Nassau County, about 40 minutes from Manhattan by train—undertake a gradual expansion from its original mission. South Shore’s energetic director Mary Lou Jones, a 25-year veteran of social work with people who have substance use and mental health conditions, started the first sanctioned program in New York State for the treatment of children of addicts in Freeport. Aiding children and families remains South Shore’s core mission—something that is clear to visitors the moment they walk into the toy-strewn waiting room, where the cartoon movie “Finding Nemo” blares from a TV.

Sabino—a 41-year-old who speaks in an accent flecked by his native Queens and who came to South Shore after getting his master’s degree in social work—said that as the center grew over the years, staff members realized that one of the best things it could do for children from Long Island’s South Shore was to offer more programs targeting adults who were falling through the cracks of the social service safety net. “We now have a lot of versatility,” said Sabino, who said that about 70% of the center’s clientele are now adults—even though it continues its extensive work with kids.

Still, South Shore staff members noted that when CEIC’s evaluators did a top-to-bottom examination for the first time of how well the center integrated its services for clients coping with both addiction and mental illness, its score was only middling—perhaps understandable given the changing nature of the program.

In response, the CEIC team recommended a number of ways that the center could improve its services. Some of the recommendations were quite simple—for example, changing the center’s online mission statement to reflect its emphasis on treating clients with co-occurring conditions, or placing literature in the waiting room that touched on the connections between mental illness and drug or alcohol use.

Other changes that were proposed by CEIC were more substantial. The most critical one, according to Sabino, centered on using a different intake screening exam that is better geared toward diagnosing patients with co-occurring conditions. Also, Sabino—and other caseworkers at South Shore—said the review led to a number of changes in group therapy discussions that were helpful, even though some of the suggestions were fairly simple.

“Even just remembering to bring the psychiatrist’s appointment book into the group, so we make sure that they all see the psychiatrist, or that no one goes off his meds, that is helpful,” he said. Meanwhile, the conversations within the groups have been refined in response to CEIC’s recommendations, so that clients feel comfortable discussing depression, or that those with anxiety issues are encouraged to keep coming, even if they are too shy to speak.

Sabino said that after a follow-up visit from a CEIC staff member, the South Shore caseworkers made another adjustment to focus more on the connection between trauma, such as domestic abuse, and co-occurring conditions.

The push to better treat clients with addiction and mental illness, Sabino said, has helped the South Shore program flourish even in the face of local budget cuts that forced some reductions in staff members and hours. “Here,” he explained, “there’s no wrong door.”

About this Initiative
 

In New York State, 50% of people who suffer from a mental health disorder are simultaneously struggling with some form of substance use. Yet studies show that fewer than 1 of every 10 residents who have both substance use and mental health conditions (often called co-occurring disorders) receive evidence-based treatment for both conditions. Undiagnosed and untreated co-occurring conditions can lead to painful and costly human and social consequences, such as homelessness, encounters with the criminal justice system, and even suicide.

NYSHealth invested in a five-year initiative to improve the integrated clinical care for people with co-occurring disorders. In 2008, it established the Center for Excellence in Integrated Care (CEIC) to help mental health and substance use programs across the State make changes to address people's mental health and substance use problems at the same time. By 2013, CEIC exceeded its target of working with 600 of the estimated 1,000 licensed mental health and substance use programs across the State. An article in the October 2013 issue of Health Affairs examined the clinical aspects of this initiative and provided an analysis of the statewide efforts and impact to improve integrated care. Also in October 2013, NYSHealth hosted a conversation with the CEIC team, other health experts, and a client with co-occurring conditions to discuss the outcomes and lessons learned from this initiative.

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