A look at: Co-Occurring Disorders, and Barriers to Employment

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A look at Co-Occurring Disorders, and Barriers
to Employment

• Roland Williams, MA, NCACII, CADCII, SAP
• President, Free Life Enterprises,
• Director, VIP Recovery Coaching
• www.rolandwilliamsconsulting.com

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Addressing Substance Abuse and Mental Health
Barriers to Providing Services

• Co-Occurring Mental Health and Substance Abuse
  creates unique challenges regarding screening and
  assessment, service coordination, treatment
  capacity, and funding for services.
• Identifying and assessing rclients with substance
  abuse and mental health problems are first steps
  in dealing with these barriers to employment.
• Types of practices that can facilitate accurate
  screening and assessment include staff training
  on substance abuse and mental health issues, and
  the use of appropriate screening instruments.
• Once problems are identified, referral to
  treatment and providing support services can
  improve recipients social functioning and
  employment outcomes. Access to treatment can be
  difficult, however, because service delivery
  systems are often fragmented.
• Referring clients to treatment may also bring to
  light service capacity problems, particularly for
  programs designed to serve women with children.
• Limited funding for treatment services and
  limited coverage of these health-related problems
  through MediCal may be further obstacles to
  treatment.

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• An Introduction to Co-Occurring Disorders

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Substance Abuse and Mental Illness

• A dual diagnosis or co-occurring disorder
  occurs when an individual is affected by both
  chemical dependency and mental illness. Both
  illnesses may affect a person physically,
  socially, psychologically, and spiritually. Each
  illness has symptoms that interfere with a
  persons ability to function effectively. The
  illnesses may affect each other, and each
  disorder predisposes to relapse in the other
  disease. At times the symptoms can overlap and
  even mask as each other, making treatment and
  diagnosis difficult. To fully recover, a person
  needs to treat/address both disorders.

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How Common is a Dual Diagnosis?

• It is challenging to determine conclusively how
  many people have a dual diagnosis because
  existing studies examine different populations
  and utilize different screening tools.
• Further, people with dual disorders are
  frequently misidentified, as diagnosis can be
  more difficult because one disorder can mimic
  another. Varying sources of information have
  found that
• 37 of alcohol abusers and 53 of drug users also
  have at least one serious mental illness

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How Common is a Dual Diagnosis?

• Of all people diagnosed as mentally ill, 29
  abuse either alcohol or drugs.
• In 1993, as many as 50 of the mentally ill
  population were reported to have a substantial
  abuse problem.
• In 2002, depending on the setting, prevalence
  rates for the co-occurring disorders (dual
  diagnosis) ranged from 20 to 80
• Relapse rates for substance use are higher for
  people with a concurrent mental disorder, as are
  the chances that symptoms of mental illness will
  return for those with a concurrent substance use
  problem.

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Diagnosis 1

• MENTAL ILLNESS

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What is Mental Illness

• Mental Illness Facts
• Mental illnesses are medical conditions that
  disrupt a persons thinking, feeling, mood,
  ability to relate to others, and daily
  functioning. Just as diabetes is a disorder of
  the pancreas, mental illnesses are medical
  conditions that often result in a diminished
  capacity for coping with the ordinary demands of
  life.

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Serious mental illnesses

• Include
• major depression
• schizophrenia
• bipolar disorder
• obsessive compulsive disorder (OCD)
• panic disorder
• post traumatic stress disorder (PTSD)
• borderline personality disorder

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In Addition to Medication Treatment

• Psychosocial treatment such as
• cognitive behavioral therapy,
• interpersonal therapy,
• peer support groups,
• and other community services can also be
  components of a treatment plan that assist with
  recovery.
• The availability of transportation, diet,
  exercise, sleep, friends, and meaningful paid or
  volunteer activities contribute to overall health
  and wellness, including mental illness recovery.

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Diagnosis Specific Signs and Symptoms
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Major Depression

• Dysphoric mood
• At least 4 of the following
• Changes in appetite and sleep patterns,
  agitation, loss of interest in pleasurable
  activities, fatigue, worthlessness, guilt,
  inability to concentrate, ruminating negative
  thoughts, feeling helpless and hopeless,
  recurrent thoughts of death

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Signs and Symptoms of Depression

• Tearful
• Changes in sleeping patterns
• suicidal ideation
• changes in appetite
• loss of pleasure
• isolation
• sudden outburst of anger

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Signs and Symptoms of Depression

• Difficulty concentrating
• Ruminating thoughts
• Feeling helpless
• Feeling hopeless
• Feeling like life is not worth living
• Ruminating on negative thoughts
• Emotional numbness

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Bipolar Disorder

• Bipolar disorder, also known as manic depression,
  is a brain disorder that causes unusual shifts in
  a person's mood, energy, and ability to function.
  Different from the normal ups and downs that
  everyone goes through, the symptoms of bipolar
  disorder are severe. They can result in damaged
  relationships, poor job or school performance and
  even suicide.

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Bipolar Disorder Manic

• One of more distinct period with a predominantly
  elevate, expansive or irritable mood
• Duration of at least one week during which most
  of the time at least 3 have been present
• Increase in activity, hyper verbal or pressured
  speech, flights of ideas, grandiosity, decreased
  need for help, distractibility, buying sprees,
  sexual indiscretions, foolish business
  investments, reckless driving

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Post Traumatic Stress Disorder

• Diminished interest in activities
• Feeling detached or estranged from others
• Sleep disturbances
• Hyper alertness
• Exaggerated startle response
• Survival guilt
• Memory impairment, difficulty concentrating
• Intensification of symptoms by exposure to events
  that symbolize or resemble the traumatic event

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Personality Disorders

• Each of us has a personality or group of
  characteristics (traits) which influence the way
  we think, feel behave and makes us a unique
  individual.
• Someone may be described as having a 'personality
  disorder' if their personal characteristics cause
  regular and long term problems in the way they
  cope with life and interact with other people.
  Some people with these disorders never come into
  contact with the mental health services.
• APA when personality traits are inflexible
  and maladaptive and cause either significant
  impairment in social or occupational functioning
  or subjective distress.

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Personality Disorders

• Approximately 10-13 of the population have a
  personality disorder. Personality disorders are
  more common in younger age groups (25-44 year age
  group) and are equally distributed between males
  and females.

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Personality Disorders

• Prominent characteristics
• Tx of problematic relationships
• Blames difficulties on others or bad fortune
• Doesnt learn from mistakes
• Generate and perpetuate existing problems
• Lack of control over emotions
• Distorted thinking

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Types of Personality Disorders

• Divided into 3 Clusters
• A) odd/eccentric paranoid, schizoid
• B) dramatic/erratic antisocial, borderline,
  histrionic, narcissistic
• C) anxious/inhibited dependent, avoidant,
  obsessive-compulsive

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Antisocial Personality Disorder

• Current age of at least 18
• Onset before 15 as indicated by 3 or more
• Truancy, expulsion, delinquency, running away
  from home, arrested, persistent lying, repeated
  sexual intercourse, repeated drunkenness or
  substance abuse, thefts, vandalism, low school
  grades, chronic violations of home rules,
  initiation of fights

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Antisocial Personality Disorder

• At least 4 of the following since age 18
• Inability to sustain consistent work behavior
• Lack of ability to function as a responsible
  parent
• Failure to accept social norms with respect to
  lawful behavior
• Inability to maintain enduring attachment to a
  sexual partner

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Antisocial Personality Disorder

• Irritability and aggressiveness
• Failure to honor financial obligations
• Failure to plan ahead or impulsivity
• Disregard for the truth
• Recklessness
• A pattern of continuous antisocial behavior in
  which the rights of others are violated

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Borderline Personality Disorder

• At least 5 of the following
• Impulsivity or unpredictability in at least 2
  areas that are potentially self
  damaging-Spending, sex, gambling, shoplifting,
  AOD use, etc
• A pattern of unstable and intense interpersonal
  relationships
• Inappropriate, intense anger or lack of control
  over anger
• Identity disturbances
• Affective instability
• Intolerance of being alone
• Physical self damaging acts
• Chronic feelings of emptiness and boredom

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Post Traumatic Stress Disorder

• The person has been exposed to a traumatic event
  in which the person experienced, witnessed, or
  was confronted with an event or events that
  involved actual or threatened death or serious
  injury, or a threat to the physical integrity of
  self or others and the person's response involved
  intense fear, helplessness, or horror. The
  disturbance, which has lasted for at least a
  month, causes clinically significant distress or
  impairment in social, occupational, or other
  important areas of functioning.
• The traumatic event is persistently reexperienced
  in one or more of the following ways

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Post Traumatic Stress Disorder

• Recurrent and intrusive distressing recollections
  of the event, including images, thoughts, or
  perceptions.
• Recurrent distressing dreams of the event.
• Acting or feeling as if the traumatic event were
  recurring (includes a sense of reliving the
  experience, illusions, hallucinations, and
  dissociative flashback episodes, including those
  that occur on awakening or when intoxicated).

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Post Traumatic Stress Disorder

• Intense psychological distress at exposure to
  internal or external cues that symbolize or
  resemble an aspect of the traumatic event
• Physiological reactivity on exposure to internal
  or external cues that symbolize or resemble an
  aspect of the traumatic event

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Post Traumatic Stress Disorder

• The individual also has persistent avoidance of
  stimuli associated with the trauma and numbing of
  general responsiveness (not present before the
  trauma), as indicated by 3 or more of the
  following
• Efforts to avoid thoughts, feelings, or
  conversations associated with the trauma
• Efforts to avoid activities, places, or people
  that arouse recollections of the trauma
• Inability to recall an important aspect of the
  trauma
• Significantly diminished interest or
  participation in significant activities

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Post Traumatic Stress Disorder

• Feeling of detachment or estrangement from others
• Restricted range of affect (e.g., unable to have
  loving feelings)
• Sense of a foreshortened future (e.g., does not
  expect to have a career, marriage, children, or a
  normal life span)

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Post Traumatic Stress Disorder

• Persistent symptoms of increased arousal (not
  present before the trauma), as indicated by 2 or
  more of the following
• Difficulty falling or staying asleep
• Irritability or outbursts of anger
• Difficulty concentrating
• Hypervigilance
• Exaggerated startle response

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The Good News About Mental Illness

• Is that recovery is possible.
• Mental illnesses can affect persons of any age,
  race, religion, or income.
• Mental illnesses are not the result of personal
  weakness, lack of character, or poor upbringing. 
• Most people diagnosed with a serious mental
  illness can experience relief from their symptoms
  by actively participating in an individual
  treatment plan.

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Diagnosis 2

• SUBSTANCE ABUSE

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The Three Cs of Addiction

• Control
• Early social/recreational use
• Eventual loss of control
• Cognitive distortions (denial)
• Compulsion
• Drug-seeking activities
• Continued use despite adverse consequences
• Chronic Condition
• Natural history of multiple relapses preceding
  stable recovery
• Possible relapse after years of sobriety

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Addiction A Dog with a Bone

• It never wants to let go.
• It bugs you until it gets what you want.
• It never forgets when/where it is used to
  getting its bone.
• It thinks its going to get a bone anytime I do
  anything that reminds it of the bone.

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Addiction Defined

• Drug Addiction is a complex illness. It is
  characterized by compulsive, obsessive and at
  times uncontrollable craving, seeking and use
  that persist even in the face of extremely
  negative consequences. Denial, minimizing and
  rationalizing the use and effects prolong the
  illness. For many, addiction becomes chronic,
  with relapses possible even after long periods of
  abstinence.

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DSM-IV Criteria

• Substance Abuse (need 1 in 12 mo. Period)
• Use leads to impairment or distress by
• Failure to fulfill major roles, obligations
• Use in hazardous situations
• Recurrent legal problems
• Continued use despite problems
• Symptoms never met criteria for substance
  dependency

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DSM-IV Criteria

• Substance Dependence (need 3 in 12 mo. Period)
• Use leads to impairment or distress by
• Tolerance
• Withdrawal
• Loss of control
• Failed attempts at control or abstinence
• Much time spent, getting, using or recovering
• Given up or reduced job or recreational activity
• Continued use despite known negative consequences

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Common Sense Assessment
financial
work
spiritual
family
emotional
social
recreational
physical
legal
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When to be Suspicious

• Unexplained changes in appearance, attitude and
  overall health
• Family concerns or turmoil
• Drug seeking behavior
• Loss prescriptions
• Chronic pain complaints
• Unexplained weight loss
• Missed appointments
• Lying or inconsistencies in self-report
• Increased parenting problems

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• Substance Abuse and Mental Illness Co-Occurring
  Disorder

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Current Terminology

• Dual diagnosis is an unfortunate misnomer, as
  rarely do people experience ONLY two disorders.
  SAMHSA favors the term, co-occurring disorders.
  One type of disorder may trigger the other, but
  90 percent of the time, according to National Co
  morbidity Survey (NCS) data, mental illness
  precedes substance use. On average, mental
  illness occurs at around age 11 followed by
  substance use five to 10 years later. On the
  other side of the coin, drug use can produce
  psychotic symptoms, result in a relapse of a
  psychotic illness, or create a need for
  medication adjustments.

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Other names for this condition

• Co-morbid disorders
• Co-occurring disorders
• Concurrent disorders
• Co-morbidity
• Dual disorders
• Dual diagnosis

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Co-Occurring Risk Factors

• Childhood risk factors such as poverty, family
  discord, and pre and postnatal complications
  appear to be implicated in both mental illness
  and substance use.
• Between 51 and 97 percent of women with serious
  mental illness have been physically or sexually
  abused.
• 41 to 71 percent of women treated for alcohol or
  drug use report being sexually abused.

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Stigmas

• Alcohol and drug abuse have many negative
  connotations in our society. For many, drug abuse
  is perceived to result from lack of willpower,
  laziness, or selfishness. Sadly, these erroneous
  perceptions also extend to a group extremely
  vulnerable to drug abuse people with mental
  disorders.

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Relationship between Substance Abuse and Mental
Illness

• Those with a mental disorder can be very
  sensitive to the effects of drug abuse not only
  can it be easier to abuse drugs, it can also be
  harder to quit.
• Like the rest of the population, a person with a
  mental disorder is more likely to abuse drugs if
  there is a family history of alcohol and drug
  abuse.
• Environmental factors such as peer pressure,
  location, and the availability of the drug also
  contribute to a pattern of drug abuse in the
  mentally ill.

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Relationship between Substance Abuse and Mental
Illness, cont.

• Drug use can interfere with prescribed
  medication, increase symptoms of a mental
  condition, and increase relapse risk.
• Having difficulty developing social
  relationships, some people find themselves more
  easily accepted by groups whose social activity
  is based on drug use.
• Some believe that an identity based on drug
  addiction/alcoholism is more acceptable than one
  based on mental illness.

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So are we doing to provide more comprehensive and
effective treatment to the Dual Diagnosis Client?
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The Need for Dual Recovery

• A person with a dual diagnosis may sincerely try
  to recover from one illness and not acknowledge
  the other.
• As a person neglects the mental illness, that
  illness may resurface. This recurrence may in
  turn lead a person to feel the need to self
  medicate through drug/alcohol use to combat
  symptoms of the mental illness or side effects of
  medications.

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The Need for Dual Recovery

• This relief or change is temporary at best and
  usually leads to hospitalization. Over time, the
  lack of progress towards recovery on both fronts
  may
• Trigger feelings of failure and alienation
• Lead to trouble with parenting, finding and
  keeping employment, housing, and non-tolerance in
  rehabilitation or treatment facilities
• Lead to loss of support systems and benefits
• Result in frequent relapses and hospital stays.

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How is a Co-Occurring Disorder Treated?

• Programs historically have not addressed the
  unique problems of those struggling with both
  disorders, instead treating the mental illness
  and drug abuse as separate problems. This has not
  proved to be an effective approach and more
  programs now are being developed to treat both
  disorders together.
• Ideally, both problems should be treated
  simultaneously.

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How is a Co-Occurring Disorder Treated?

• A person with a Co-Occurring Disorder may or may
  not fit into traditional 12-Step groups.
• Opportunities to socialize and access to
  recreational activities to develop peer
  relationships
• Attendance in groups that deal with education and
  awareness of dual diagnosis issues, medication
  support and management, life skills, and wellness
• Family support and education

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How is a Co-Occurring Disorder Treated?

• The first step in treatment for any substance
  abuse must be detoxification
• For safety, detoxification should take place
  under medical supervision.
• Treatment programs for this population should
  take a gradual approach. Those with dual
  diagnosis have to proceed at their own pace in
  the treatment process.
• Abstinence may be a goal of the program but
  should not be a pre-condition to enter treatment

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General Rules

• Meet the recipients where theyre at
• Acknowledge and allow them to have emotional,
  cognitive, behavioral and intellectual
  limitations
• Develop action plans according to where they are
  and not where you think they should be
• Set the client up to succeed not fail

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Responsible and Careful Assessment

• To begin treatment based solely on the appearance
  of psychiatric symptoms denies the person
  accurate diagnosis
• Need to distinguish between substance use
  disorder, substance-induced problems, self
  medication of a primary mental disorder, or true
  dual diagnosis.
• careful assessment rather than reactive treatment
  of presenting symptoms
• pharmacological and psychosocial aspects of
  addiction can mimic psychiatric disorders.
• What can appear to be a significant major
  depression can dissipate decisively with
  abstinence and recovery It is equally important
  to avoid persistent admonition to not drink and
  go to meetings if there is a primary depressive
  disorder, which the client attempts to self
  medicate with alcohol. David Mee-Lee

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The Four Quadrant Model

• The Four Quadrant Model is a viable mechanism
  for categorizing individuals with co-occurring
  disorders for the purpose of service planning and
  system responsibility.

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Sub-Groups of Dual Diagnosis Client Types
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Choosing the Right Program

• There are several different levels of care,
  including full hospitalizations, partial
  hospitalizations, and out patient treatment. The
  need for hospitalization depends on the nature
  and severity of illness, the associated risk or
  complication, and personal treatment history.
  Because both illnesses are treated at the same
  time, a person needs to be able to take
  psychiatric medications while treating the
  substance abuse. So choosing the right program is
  crucial for successful outcomes.

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AOS Programs

• Programs that offer Addiction-Only Services (AOS)
  
• Some addiction treatment programs cannot
  accommodate patients with psychiatric illnesses
  that require ongoing treatment, however stable
  the illness and however well functioning the
  individual. Such programs are said to provide
  Addiction-Only Services (AOS).

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DDC Programs

• Dual Diagnosis Capable (DDC) Programs
• Dual Diagnosis Capable (DDC) programs routinely
  accept individuals who have co-occurring mental
  and substance-related disorders. DDC programs can
  meet such patients needs so long as their
  psychiatric disorders are sufficiently stabilized
  and the individuals are capable of independent
  functioning to such a degree that their mental
  disorders do not interfere with participation in
  addiction treatment.

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DDE Programs

• Dual Diagnosis Enhanced (DDE) Programs
• DDE programs can accommodate individuals with
  dual diagnoses who may be unstable or disabled to
  such an extent that specific psychiatric and
  mental health support. monitoring and
  accommodation are necessary in order for the
  individual to participate in addiction treatment.
  Such patients are not so acute or impaired as to
  present a severe danger to self or others, nor do
  they require 24-hour, intensive psychiatric
  supervision.

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Treatment Providers Should

• Take good history A definitive psychiatric
  diagnosis by history requires the psychiatric
  symptoms to have occurred during drug-free
  periods of time and/or to have preceded the
  beginning of addiction problems.
• Observe the client for a sufficient time
  drug-free Shorter time for objective, psychotic
  symptoms longer for subjective, affective
  symptoms. Clients are encouraged to try non-drug
  ways of coping such as active involvement in a
  recovery program that incorporates self/mutual
  help meetings, tools, techniques, and a wide
  variety of non-drug coping responses to help
  clients deal with the stresses of everyday
  living.
• If there is evidence of a documented co-occurring
  mental disorder, then no drug-free period is
  necessary.

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Typical Response to Treatment

• Dual diagnosis clients were more often discharged
  due to determinations that the individuals were
  inappropriate for the treatment program or for
  program decisions related to patient
  non-compliance with rules.
• Substance abuse clients were more likely to be
  transferred to another level of service or
  referred out of the system for alternative
  services.
• In one study the two groups were equivalent in
  the percentage of clients who completed
  treatment, when placed in the appropriate
  clinical setting.

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Co-Occurring Recovery and Relapse Calendar
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Negative Outcomes among Dually Diagnosed
More relapses, re-hospitalization, depression,
suicides, violence, housing instability and
homelessness, treatment noncompliance , HIV,
family burden, increased service utilization and
certainly difficulty and/or inability to acquire
and maintain gainful employment, and for Calworks
caseload, the inability to meet the work
requirements and possible loss of benefits.

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Individuals with Co-occurring DisordersTreatment
Rules

• All good treatment proceeds from empathic,
  hopeful, clinical relationship.
• Consequently, promote opportunities to initiate
  and maintain integrated, continuing, empathic,
  hopeful relationships whenever possible.
• Specifically, remove arbitrary barriers to
  initial mental health assessment and evaluation,
  including psychopharmacology evaluation.
• Similarly, never deny access to substance
  disorder evaluation and/or treatment because a
  patient is on a prescribed non-addictive
  psychotropic medication.
• Moreover, never discontinue medication for a
  known serious mental illness because a patient
  uses substances.

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Individuals with Co-occurring DisordersTreatment
Rules Continued

• In fact, when mental illness and substance
  disorder co-exist, both disorders require
  specific and appropriately intensive primary
  treatment.
• There are no rules! The specific content of dual
  primary treatment for each person must be
  individualized according to diagnosis, phase of
  treatment, level of functioning and/or
  disability, and assessment of level of care based
  on acuity, severity, medical safety, motivation,
  and availability of recovery support. Kenneth
  Minkoff, M.D

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The Self-Medication Theory

• People with serious mental illness use
  substances
• To alleviate general feelings of isolation,
  loneliness, boredom, and despair,
• To facilitate peer interaction/socialization
• To create a sense of well-being, and escape from
  bleak life experience. Sound familiar?

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FOUR STEP PROCESS

• Empathize with reality of despair.
• Establish legitimacy of their need to ASK for
  extensive help.
• 3. Identify meaningful, attainable measures of
  successful progress.
• 4. Emphasize a hopeful vision of pride and
  dignity to counter self-stigmatization.

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Individuals with Co-occurring DisordersPrinciples
of Successful Treatment

• Co morbidity is an expectation, NOT an exception.
  
• Use the Four Quadrant Model.
• Treatment success derives from the implementation
  of an empathic, hopeful, continuous treatment
  relationship, which provides integrated treatment
  and coordination of care through the course of
  multiple treatment episodes.
• Within the context of the empathic, hopeful,
  continuous, integrated relationship, case
  management/care and empathic detachment/
  observation are appropriately balanced at each
  point in time.
• When substance disorder and psychiatric disorder
  co-exist, each disorder should be considered
  primary, with integrated treatment. Each disorder
  receives appropriately intensive
  diagnosis-specific treatment.

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Individuals with Co-occurring DisordersPrinciples
of Successful Treatment

• Both major mental illness and substance
  dependence are examples of primary mental
  illnesses which can be understood using a disease
  and recovery model, with parallel phases of
  recovery, each requiring phase-specific
  treatment.
• There is no one type of dual diagnosis program or
  intervention. For each person, the correct
  treatment intervention must be individualized
  according to diagnosis, phase of
  recovery/treatment, level of functioning and/or
  disability associated with each disorder, and
  level of acuity, dangerousness, motivation,
  capacity for treatment adherence, and
  availability of continuing empathic treatment
  relationships and other recovery supports.

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Strategies that Support Success

• Medication for addiction is presented as
  ancillary to a full recovery program that
  requires work independent of medication.
  Individuals on proper medication must work as
  hard as those with addiction only.
• Distinguish normal feelings from disorders with
  similar names (anxiety, depression)
• Psychiatric medications are directed to known or
  probable disorders, not to medicate feelings
• Proper medication for mental illness does not
  take away normal feelings, but permits patients
  to feel their feelings more accurately.
• Use fixed dosage regimes, not prn, (as needed)
  meds.

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More Strategies for Success

• Pain Management should occur in collaboration
  with a prescribing physician who is fully
  informed about the status of substance use
  disorder
• Individuals addicted to opiates for non-specific
  neck, back, etc. conditions can be informed that
  continued use of opiates worsens perceived pain.
  Full withdrawal plus alternative pain management
  strategies can actually improve pain in the long
  run.

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Resources

• ASAM
• NAMI
• NIDA
• SAMHSA
• DRA
• AA, NA, CA
• SMART RECOVERY, LIFERING

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Opportunities for Interventions

• Building Self-Efficacy and engagement strategies
• Screening
• Opportunity for Interventions (services,
  referrals, funding)
• Co-locating services
• Funded integrated quality treatment
• Recovery/employment retention support services
• Employment and Family/Survival Resources
• Accountability
• Outreach for Sanctioned Families

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Working Together

• Evaluate current status of planning, policies and
  programs to address substance abuse and mental
  health employment barriers
• Assess new opportunities and challenges related
  to reauthorization use this opportunity to plan
  for system improvements
• Prevent or eliminate policies designed for
  individual or program failure
• Compassion and respect

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In Summary

• A significant proportion of clients may suffer
  from mental health and/or substance abuse
  problems that impede their ability to participate
  in required program activities and move
  successfully into the workplace. Others may have
  caretaking responsibilities for a family member
  who suffers from mental illness or substance
  abuse. These employment barriers pose unique
  challenges to agencies, which must meet the
  treatment needs of these individuals as well as
  work participation requirements. We are further
  challenged by ongoing budget constraints that
  limit agency resources and the availability of
  treatment options.