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Co-Occurring Disorders

Special Issues in Substance Abuse Treatment: Co-Occurring Disorders

TCA believes that a co-occurring disorder can include a full range of mental health disorders, socioeconomic issues, medical conditions, and psychological traumas. This article will focus only on co-occurring substance use and mental disease disorders.

In recent years, the treatment of co-occurring disorders has risen to prominence as a significant issue for those in both the substance abuse treatment and mental health fields. For the purposes of this article, Co-occurring disorders refer to co-occurring substance use and mental disease disorders. Since the 1970’s, treatment providers in both fields have recognized and documented the high numbers of their patients that have such co-occurring disorders. Greater research and clinical study have led to both growing awareness of the issue and more effective treatment protocols to respond to it.


The latest figures suggest that co-occurring disorders are common in the adult population, particularly among those with an existing mental disease or substance use disorder. The National Survey on Drug Use and Health (NSDUH) found that in 2002, 4 million adults met the criteria for both serious mental illness and substance abuse. Other research suggests that this figure may be as high as 10 million people when adolescents, the institutionalized, and those with less serious (but still diagnosable) mental disease disorders are counted. 

Treatment of Co-Occurring Disorders in Therapeutic Communities

Many of the programs at the forefront of the development of co-occurring treatment programs are therapeutic communities. The holistic approach of the Therapeutic Community has proven to be highly adaptable and particularly well suited to treat the complex issues faced by patients with co-occurring disorders. Some program directors have started new co-occurring-only programs, while others have integrated co-occurring treatment into that of their general client population.

For instance, Dr. Ken Bachrach, a clinician at Southern California-based TCA member Tarzana Treatment Center, notes that psychiatric services are provided in all of Tarzana’s programs. Of Tarzana’s long-term residential patients, Dr. Bachrach estimates that 30-50% have a co-occurring disorder.

Similarly, New York City-based TCA member Palladia runs a 384-bed facility with integrated co-occurring treatment. “On any given day, approximately one-third to one-half of the residents have co-occurring disorders,” says Susan Ohanesian, Vice President for Residential Services.

TCA member Odyssey House Inc., also of New York City, provides basic mental health services in its general population substance abuse treatment center. Odyssey House also runs a 60-bed co-occurring-only program for severely persistent mentally ill, chemically addicted homeless men and women, which incorporates many of the basic elements of the therapeutic community, but uses a more individualized approach that incorporates pharmacological and psychological therapies.

According to John Tavolacci, Odyssey House Senior Vice President and Chief Operating Officer, there are both structural and clinical reasons for having separate facilities. “In New York State, there are different state agencies for substance abuse treatment and mental health. We don’t really get funding to treat patients among the general (substance abuse) population.” For this reason, Odyssey House limits clients with serious mental illnesses, such as bipolar disorder or schizophrenia, to their specialized co-occurring program. This allows the organization to provide them with crucial state-funded mental health services, such as psychiatric counseling and nursing care.

Those with less debilitating mental health problems are placed in Odyssey House’s general treatment centers. “Therapeutic communities can be anxiety-provoking, so we try to screen out those with major mental illnesses in our general program,” says Tavolacci.    

Special Considerations for the Co-Occurring Client

Indeed, many TCA members interviewed for this article remarked on the special challenges presented by co-occurring clients.

“Co-occurring clients require services that acknowledge their mental illness with the same level of importance as their substance abuse problems,” says Dennis McCray, a Vice President of the California-based TCA member Center Point Inc. “Ongoing evaluation of medication and mental status, the connection between mental illness, addiction and relapse, and self-care should be addressed with clients and included in aftercare planning. “

Carol Davidson, Veterans Program Director at New York City-area TCA member Samaritan Village, notes that co-occurring clients can require changes to the common clinical practices of therapeutic communities. “Within the therapeutic community model, modifications must be made to work within the parameters of the clients’ ability to tolerate and/or benefit from standard interventions (confrontation, behavior modification, etc).”

Specialized Treatment of Co-Occurring Disorders

Some therapeutic communities have been modified even further, allowing them to provide co-occurring services to special populations. For instance, Samaritan Village runs a residential program specifically for male combat veterans. Davidson estimates that typically between 50 – 75% of this population has a mental health diagnosis of some kind; post-traumatic stress disorder is particularly common among the group. Says Davidson, “treatment planning is individualized to a large degree so that clients can receive different services according to specific needs, such as individual sessions with Social Work staff or participation in a Dual Recovery Group.”

As another example, Palladia runs a co-occurring program specifically for women with children, called the Dreitzer Women and Children’s Program. The facility provides substance abuse and mental health services to mothers and provides a safe learning environment for their children, as well as prenatal care for expecting mothers. The Dreitzer Program treats 25 mothers and 25 children in a residential setting for 12 to 15 months.

Co-occurring programs have also been developed for prison populations. Center Point runs several in-prison therapeutic communities throughout California; approximately 14% of all clients in these programs receive mental health services. “Services are provided to the dually diagnosed population using a multi-disciplinary approach,” says McCray. “Center Point’s drug treatment staff works in close coordination with institutional mental health staff to provide comprehensive group and individual dual diagnosis services.”

Policy Issues

Fortunately, some federal policymakers have begun grappling with some of the issues involved in treating co-occurring disorders. For instance, in its 2003 report, The President’s New Freedom Commission on Mental Health clearly identified the value of treatment for co-occurring disorders: “Early intervention and appropriate treatment can also reduce pain and suffering for children and adults who have or who are at risk for co-occurring mental and addictive disorders.”

The U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) has recognized treatment of co-occurring disorders as one of their major policy concerns. The agency’s Strategic Action Plan for Fiscal Years 2004 and 2005 calls for building infrastructure, identifying best practices, and providing technical assistance for treating co-occurring disorders. And in 2005, SAMHSA released a Treatment Improvement Protocol (TIP 42) dedicated to disseminating the latest information on the appropriate care and treatment of clients with co-occurring disorders.

Nevertheless, obstacles to providing comprehensive and effective care for those with co-occurring disorders remain. A recently released Institute of Medicine (IOM) report, entitled “Improving the Quality of Health Care for Mental and Substance-Use Conditions,” pointed to many of these issues.

One problem is the co-occurring workforce shortage. The IOM report, echoing an earlier SAMHSA report, states, “One of the most significant program-level barriers noted by consumers and family members as well as providers…is the lack of staff trained in treating co-occurring disorders.”

"Co-occurring clients require more individualized attention, thus requiring an enriched staff/client ratio within a program,” says Davidson. “More highly qualified staff are required, and all staff that work with these clients require on-going training and supervision.”

“More staffing time and medications are needed for those with COD, which is not paid for as part of usual addiction funding,” says Dr. Bachrach. “We have to look for people that have training and knowledge of both substance abuse and co-occurring disorders. It can be hard to find those individuals. We often have to do our own training of drug counselors in mental health, which imparts an extra burden and cost.”

According to McCray, “decision makers must launch a concerted effort to further join the substance abuse and mental health treatment communities together. Funding and reimbursement for substance abuse services should also include the increased costs for employing mental health professionals whom historically have been compensated at a higher rate than substance abuse treatment professionals.”

Tavolacci concurs. “We need to provide funding to therapeutic communities with an emphasis on teaching staff the mental health skills needed to treat co-occurring patients. Total integration [of service delivery] is needed.”

Therapeutic Communities and the Future of Co-Occurring Treatment

While it is clear that more work needs to be done to allow improved co-occurring services, therapeutic communities are already playing a unique role in treating clients with co-occurring mental disease disorders and substance use disorders. These programs are at the cutting edge of co-occurring service delivery, and will continue to break new ground in refining the skills and methods needed to treat co-occurring disorders.

More information on co-occurring disorders can be found in the following publications:

Improving the Quality of Health Care for Mental and Substance-Use Disorders. Institute of Medicine, National Academies Press, Washington D.C, 2006. May be found at

TIP 42: Substance Abuse Treatment For Persons With Co-Occurring Disorders. US. Department of Health and Human Services: Substance Abuse and Mental Health Services Administration, Rockville, MD, 2005.
May be found at  

Achieving the Promise: Transforming Mental Health Care in America. The President’s New Freedom Commissionon Mental Health. Rockville, MD, 2003. May be found at