There was a time when the mental health component of addiction care was a best-kept secret at Hazelden. But those times are long gone.

"There was the fear that if you treated the mental health disorder, you'd get away from treating the person's addiction," says Sue Hoisington, PsyD, executive director of Hazelden's Clinical Services. "Some people feared we'd lose sight of our mission--that we'd become a mental health facility and depart from the Twelve Steps and chemical dependency focus. But nothing could be further from the truth."

Today, it's not a matter of treating one or the other, continues Hoisington, who joined Hazelden's mental health team 20 years ago. "We need to address addiction and co-occurring disorders--depression, anxiety, trauma, eating disorders, and more--concurrently. It used to be that mental health disorders and chemical dependency were viewed as separate, and they competed against each other. It's really only been in the last 10 years that we as a field have come to accept that an integrated model which addresses both the addiction and mental health issues concurrently in a single treatment site is best."

Separate but connected
Leslie Adair, manager of the Mental Health Clinic at Hazelden's Center for Youth and Families in Plymouth, Minn., agrees. "Addiction and co-occurring disorders need to be treated simultaneously. They are two distinct problems, but they're very much connected. If you don't address the mental health diagnosis, the patient will not successfully engage in treatment. And if the patient is not engaged, there will be no recovery."

Indeed, an integrated approach to a person with addiction and co-occurring disorders is the most effective approach. Hoisington notes that the addiction field has been slow to embrace change. It has lived a long time with myths such as "Just quit drinking and your depression will go away," or "Wait a year and see if you are still experiencing anxiety, then seek help."

Hoisington recalls a patient named Bob who had two problems: alcoholism and depression. Bob had received outpatient treatment for his addiction, but he relapsed and had multiple consequences as a result of his addiction. He checked himself into residential treatment at Hazelden's Cronin Unit in 1992.

"During his first treatment at Hazelden, Bob's depression improved," says Hoisington. "But about six months later he was back at Hazelden. He said to me, ‘Sue, I did everything they told me to do. I went to three meetings a week, got a good sponsor, had a good job, my wife and I were getting along, and I stayed away from the users and boozers. But I still felt like crap. I said to myself, if this is what recovery feels like, I don't want it.'"

Bob's depression had gotten worse, and he needed more. During this treatment, he started on anti-depressant medication, was able to manage his depression and alcoholism, and today he enjoys long-term recovery. "It was a real wakeup call for me in my career," says Hoisington. "It told me that for some of our patients, we really needed to look deeper than just the chemical dependency."

Hoisington, in only her fourth year at Hazelden when Bob got help, has contributed to the steady growth of Hazelden's mental health services. Hazelden has long been a leader in addressing the mental health issues of its patients, from the early 1960s, when Dan Anderson melded psychologists with the interdisciplinary team (to help identify psychological issues that might interfere with treatment), to today, when Hazelden provides a sophisticated, integrated approach for people with co-occurring disorders.

Increasingly complex patients
The need for mental health services is clear, as more and more patients present with increased acuity and complexity. Today at Hazelden over 60 percent of adult patients in residential care present with a co-occurring mental health disorder (whether previously diagnosed or identified by Hazelden), and more than 70 percent of young people (ages 14-25) at Hazelden's Center for Youth and Families (HCYF) have at least one co-occurring disorder. "We see the gamut at HCYF," says Adair. "From issues that mildly affect the young person to the more severe, such as bipolar disorder and eating disorders."

Each patient at Hazelden undergoes a complete mental health assessment, and those with a co-occurring condition are assigned a mental health professional. The mental health assessment includes psychological testing and an interview and psychiatric assessment as needed. Delivered by licensed mental health professionals, these assessments determine whether the patient is mentally stable to receive care and match the level of service to the severity of mental health issues. Cheryl Buechner, manager of the Center City Mental Health Center, identifies this assessment process as vital to treatment and recovery. "Differential diagnosis of the co-occurring disorders is a critical component of treatment and continuing care planning," she says.

The mental health team of psychologists, psychiatrists, marriage and family therapists, and social workers becomes fully integrated with the overall treatment plan for each patient. Education on co-occurring disorders, including lectures, is provided for patients and family members. Patients receive one-to-one sessions with a mental health professional as often as needed, as well as group therapy. Groups meet regularly to address specific disorders. Patients also benefit from a range of therapeutic approaches such as biofeedback, pain management, lifestyle balance, stress management, and insight therapies. Psychiatrists provide expert medication management.

Similarly, adolescent and young adult patients at HCYF benefit from a range of mental health groups, including Dialectical Behavioral Therapy for females, Emotions and Communications for males, a Coping Skills group to manage stress, and a group to manage attention deficit hyperactivity disorder (ADHD) symptoms.

The mental health staff is involved in all aspects of treatment, says Hoisington. For instance, that means that groups that address eating disorders and trauma are co-facilitated by a mental health professional and addiction counselor. Knowledge of one's co-occurring disorder helps the treatment staff be proactive and individualize care to prevent problems. The mental health staff also helps ensure that continuing care plans include recommendations for follow-up care to address patients' co-occurring disorders. It's also common for mental health staff to consult with referents to better understand the patient's needs.

The growth in Hazelden's mental health services has been phenomenal, says Hoisington. "We now have a full-time psychiatrist at each of our residential centers. In 1989, when I started here, we had one psychiatrist for three hours a week, and two hours of that was dedicated to a lecture and the other hour to patients. We have at least one psychologist assigned to each unit, with a ratio of one psychologist for every eight patients. Our outpatient services in Minnesota, Oregon, New York and Chicago offer a consulting mental health team of psychiatrists and psychologists. In addition, we train six new psychologists and four new psychiatrists in the area of chemical dependency and co-occurring disorders every year in our internship and fellowship programs."

'What sets Hazelden apart'
A 2005 survey found that about half of addiction treatment centers in the United States offer mental health services, but there is great variability. "What sets Hazelden apart," says Hoisington, "is our staff expertise, the scope of our services, and a fully integrated model to address addiction and co-occurring disorders concurrently. No one in the field except Hazelden offers all components identified by Dual Diagnosis Capability in Addiction Treatment, the tool to measure addiction treatment program services for persons with co-occurring disorders."

Hazelden is also proud that its mental health and chemical dependency staffs are cross-trained. That is, the mental health team receives training in addiction and the CD staff receives training on co-occurring disorders.

"I'm really impressed with the quality and thoroughness of patient assessments at Hazelden," says Bob Poznanovich, president of Addiction Intervention Resources (AIR), a referent to Hazelden. "A lot of times, we don't know what's going on with a client. I'm comfortable with Hazelden's ability to assess and deal with those coexisting issues that can often make or break recovery. Hazelden does much more in the mental health area than it gets credit for."

"We can't ignore mental health issues," says Hoisington. "We still have some patients with depression and anxiety being told by their sponsors that they should go off their medications. We have to educate our patients and all who are dedicated to recovery that we have to treat both disorders and that an integrated approach works best."

Pamphlets provide a guide for adults, adolescents with co-occurring disorders

Two pamphlets--A Guide for Adults with Co-occurring Disorders and A Guide for Adolescents with Co-occurring Disorders--have been prepared by Sue Hoisington, PsyD. The pamphlets, part of the Hazelden Client Pamphlet Series, provide direction for individuals with co-occurring mental health and substance abuse disorders.

Hoisington, executive director of Hazelden's Mental Health Services, blends personal stories with up-to-date information on (1) the prevalence of co-occurring disorders, (2) the most common mental health disorders, (3) how co-occurring disorders are diagnosed, and (4) treatment options, including the use of safe prescription medications. The pamphlets also direct readers to effective dual recovery support groups, such as Alcoholics Anonymous, Narcotics Anonymous, Dual Recovery Anonymous, and Double Trouble in Recovery. For more on the pamphlets, call 800-328-9000 or visit  our online bookstore.

Learn more about Hazelden Mental Health Centers.

--by Marty Duda, Hazelden

Published Summer 2008, The Voice