Experiential Papers InstructionsIn this area of study, there i.docx

Experiential Papers Instructions
In this area of study, there is nothing better for you as a student
than to see what takes place first-hand. You will be writing 3
papers based on your experiences, as shown below:
· Visit a minimum of 2 meetings of Narcotics Anonymous (NA)
for the second paper.
Most meetings are typically open to the public, but there are
some that are closed, so make sure you plan accordingly. After
each set of meetings (e.g., NA), you will write a paper based on
your experiences and turn it in via Blackboard according to its
due date in the Course Schedule.
NOTE: When you get to the meeting, ask who the
leader/facilitator is and introduce yourself to him/her. Explain
why you are there and get his/her okay to be present during the
meeting. Reassure them that confidentiality will be maintained
and that you are there to observe and learn. Most of the time,
you will just listen quietly and respectfully. Sometimes they
will ask you questions, but usually they will go around the
group and talk about their issues. You are discouraged you from
taking notes during the meeting (since you do not want to make
the members uncomfortable); instead, wait until you get back
home and write down your recollections, what took place, how
things were run, members’ stories that stood out to you, etc.
Hint: it would be wise to do a little research about the
organization before you go to any meetings.
Each paper must be 6–7 pages (not including title and reference
pages). [NOTE: References usually come from the
books/materials that you can find at the meeting. Ask for as
many of these brochures/pamphlets as you can and keep them
for your present and future use.] Each paper must include at
least 3–4 references in addition to the course textbooks. Current
APA edition format rules are in effect (1/2” indents, 1”

margins, double-spacing, etc.).
Required format of the paper:
· Name and Brief History of Organization (introduce what it is:
AA, NA, Al-Anon; how long has it been around; important
individuals and milestones in its development; future goals,
etc.)
· How the Meetings are Run/Organized (what helping model is
it based on; what is the “leader’s” role; how does the group
recognize success stories; what do they do for relapses, etc.)
· Personal Observations of the Meetings (what you saw; what
was interesting; observations of the group members [no names];
particular stories that caught your attention, etc.)
· Conclusion (what you learned; is it a good model of treatment;
how could you use this in your work/practice in the future, etc.)
Separate each section in current APA edition headings (Level 1
– centered and in bold, but do not show the “bullets”).
Experiential Papers Grading Rubric
Criteria
Levels of Achievement
Content
Advanced
Proficient
Developing
Not Present
Name/Brief History of Organization
16 to 18 points
Each of the following are thoroughly identified: Name and Brief
History of Organization (introduce what it is: AA, NA, Al-
Anon; how long has it been around; important individuals and
milestones in its development; future goals, etc.).
14 to 15 points
This section is not thorough in identifying the following: name
and Brief History of Organization (introduce what it is: AA,

NA, Al-Anon; how long has it been around; important
etc.).
1 to 13 points
Two or more essential elements of this section are missing:
Name and Brief History of Organization (introduce what it is:
etc.).
0 points
These things are not discussed.
Setup, Methodology/
Model of Treatment
16 to 18 points
Each of the following are thoroughly identified: How the
Meetings are Run/Organized (what helping model it is based on;
what the “leader’s” role is; how the group recognizes success
stories; what they do for relapses, etc.).
14 to 15 points
This section is not thorough in identifying the following: How
the Meetings are Run/Organized (what helping model it is based
on; what the “leader’s” role is; how the group recognizes
success stories; what they do for relapses, etc.).
1 to 13 points
Two or more essential elements of this section are missing: How
0 points
These areas are not included in the paper.
Personal Observations
15 to 17 points
Each of the following are thoroughly identified: Personal
Observations of the Meetings (what I saw; what was interesting;
observations of the group members [no names]; particular
stories that caught my attention, etc.).

13 to 14 points
This section is not thorough in identifying the following:
Personal Observations of the Meetings (what I saw; what was
interesting; observations of the group members [no names];
particular stories that caught my attention, etc.).
1 to 12 points
0 points
This is not present.
Conclusion, Good Method of Treatment
15 to 17 points
Each of the following are thoroughly identified: Conclusion
(what I learned; is it a good model of treatment; how could I use
this in my work/practice in the future, etc.).
13 to 14 points
Conclusion (what I learned; is it a good model of treatment;
how could I use this in my work/practice in the future, etc.).
1 to 12 points
0 points
Work settings and practice standards are not present.
Structure
Advanced
Proficient
Developing
Not Present
Mechanics
9 to 10 points
No grammar, spelling, or punctuation errors are present. Voice
and person are used correctly and consistently. Writing is

precise. Word choice is appropriate.
8 points
Few grammar, spelling, or punctuation errors are present. Voice
and person are used correctly. Writing style is sufficient. Word
choice is adequate.
1 to 7 points
Several grammar, spelling, or punctuation errors are present.
Voice and person are used inconsistently. Writing style is
understandable but could be improved. Word choice is generally
good.
0 points
Numerous spelling, grammar, or punctuation errors are present.
Voice and person are misused. Writing style is difficult to
understand. Word choice is poor.
APA Format Elements
9 to 10 points
Citations and format are in current APA style. Cover page,
citations, running head, and references are correctly formatted.
Paper is double-spaced with 1-inch margins and written in 12
point Times New Roman font. An Abstract is not needed.
8 points
Citations and format are in current APA style with few errors.
Cover page, citations, running head, and references are present
with few errors. Paper is double-spaced with 1-inch margins and
written in 12 point Times New Roman font.
1 to 7 points
Citations and format are in current APA style though several
errors are present. Cover page, citations, running head, and
references are included though several errors are present. Paper
is double-spaced, but margins or fonts are incorrect.
0 points
Citations are not formatted correctly. Cover page, running head,
and references are not included or not formatted correctly.
Paper is not double-spaced, margins are incorrect, or font is
incorrect.
Research Elements

9 to 10 points
Major points are supported by at least 3–4 scholarly sources in
addition to the course textbook. Paper is appropriate length of
6–7 pages.
8 points
Major points are supported by 1–2 scholarly sources in addition
to the course textbook. Paper is not the appropriate length and
is either excessively long or too brief.
1 to 7 points
Major points are supported by at least 1 scholarly source and
the textbook is not listed/or the resources are not scholarly.
Paper is not the appropriate length and is either excessively
long or too brief.
0 points
Major points are not supported scholarly sources. Paper is not
the appropriate length of 6–7 pages.
Total: /100
Instructor’s Comments:
Page 2 of 2
Running Head: ALCOHOLICS ANONYMOUS 1
ALCOHOLICS ANONYMOUS 11
Alcoholics Anonymous
Student
School
Heading?
Alcoholism is a trend that has affected several people
globally because of addiction and other issues that are related to
it (Capuzzi & Stauffer, 2016). People have been forced to find

organizations to them deal with alcoholism. Sobriety enables
people to achieve their dreams without any limitations to do
with their physical or mental state. The road to recovery might
be tough (difficult) for some people, but it is worth the fight at
the end of the day. Additionally, society begins to notice that
reforming alcohol addicts is a possible venture. Hence, there is
no justification for alienating people who might be going
through this horrible phase of their lives. This discourse entails
my verdict after attending two of the AA sessions as the
program was in progress. It will include the details of the
organization, its operations, personal observations, and my
conclusion based on my experience during my time there.
The challenges that individuals face has forced them to do some
things that they had not imagined. Every person has his or her
own story about using alcohol. Notably, the journey of
addiction is a process and not an instantaneous happening (?) as
others would think. Therefore, it is an issue that needs to be
handled with some subtle sense of precaution to avoid hurting
the individuals who could have been affected by the condition
(“The 12 Steps of AA Explained citations require author
information rather than title information,” 2018). Sobriety
happens when a person avoids any alcoholic drink that could
impair judgment (Capuzzi & Stauffer, 2016). Hence, it might be
necessary to avoid liquor if possible. However, alternative such
as harm reduction, tapering off, trial sampling, and warm turkey
is not condoned by the AA as (because, not as) they encourage
total abstinence (Capuzzi & Stauffer, 2016). Comment by
Windows User: Please edit your wording here. People are not
forced. Comment by Windows User: Select a different word
here please.
Name and Brief History of the Organization
Alcoholic Anonymous (AA) was founded in 1935 by Bill
Wilson (Capuzzi & Stauffer, 2016). Bob Smith was the other
person who was involved in the founding of the organization in
Ohio. Over the years, this entity (?) has continued to attract
people from different places as they strive to solve their

alcoholism problems. The success rate of its policies can judge
the relevance of such a body as it seeks to help individuals who
are going through tough phases in their lives. Addiction can be
traumatizing because it involves the entire family (Dick, 2007).
Please note: The published literature from AA is the best source
for information about this content section.
The society is also affected in the long run since it will lack
able-bodied young men who can contribute to the development
of the community (Capuzzi & Stauffer, 2016). Hence, several
justifications can be used to honor the existence of Alcoholics
Anonymous. Therefore, as it seems the organization has been in
existence for several years and it has also contributed to the
transformation of several lives that could have been lost
because of alcohol-related cases in the respective places.
Human life is valuable and deliberate efforts should be made to
preserve it. The inception of AA marked the beginning point of
change stories from people who had become disillusioned about
life. Acknowledging its contribution to modern day society is
very necessary.
At the time of AA's founding, it had not captured any traction
(?)among people who are affected by alcohol. However, over
time, the entity has become a renowned organization because of
its reputation as it strives to ascertain that alcoholics achieve
sobriety (Capuzzi & Stauffer, 2016). Some facts cannot be
assumed regarding alcoholism in society since people have
become enlightened through various ways (Jensen, 2000).
Therefore, it is crucial to ensure that the people who attend such
AA meetings are not stigmatized. They should be allowed to go
through the healing process without any difficulties.
Comment by Windows User: AA is not an entity. It is an
organization. Please edit your wording and your writing.
AA has helped several people towards their journey of recovery
from alcoholism. Professionals and people from different
backgrounds are not immune to the condition (Capuzzi &
Stauffer, 2016). Therefore, over the years, the organization has
been essential in transforming the lives of several people. Dick

(2007) state that AA has made significant strides towards
achieving its initial goals. AA wants to focus on holistic
recovery of alcoholic in the future (citation here please). Hence,
it shows that the close family members of the affected people
may be involved in the recovery process. Jensen (2000) wrote
about an improved format for ensuring that the effectiveness of
AA is enhanced accordingly (citation here please).
This first section is incomplete. The required content areas have
not been discussed here. Why, where, and when was the group
founded? How did it grow and spread? How many members and
groups are there now? Please consult the published AA
literature for a detailed summary of the history, development,
and growth of AA.
How Meetings are Organized
AA encompasses (?) individuals who want to abstain from
alcohol (Capuzzi & Stauffer, 2016). Hence, the people who are
involved could have been going through different phases of
their alcoholism journey. Therefore, they tend to organize
meetings where they encourage each other and share a lot of
information on how to stay free from alcohol. These individuals
are mostly on the road to recovery. Therefore, (please edit and
eliminate the repeated use of this wording at the beginning of
your sentences) they need a high level of encouragement so that
they can go through AA successfully. AA has an elaborate plan
that ensures that the participants keep away from alcohol
through all means. Its strategy is always inclusive, and the
participants are always encouraged to take part in
wholeheartedly (Dick, 2007).
Use second level headings please to organize and structure your
writing as required by APA manual guidelines.
At the meetings that I attended, there was a leader who seemed
to be in control of the whole group. He was in charge of
controlling the events that were taking place and giving every
person a chance accordingly. Sharing of stories is one of the
critical components of AA. Some of the experiences that people
have had might encourage an individual who is about to give up

on the program. AA meetings are mostly characterized by
positive connotations that are supposed to be motivational (The
12 Steps of AA Explained, 2018). Inspirational stories are
common. These types of narratives are essential because they
inform the participants that they can achieve anything that they
wish provided they remain faithful to the course of recovery.
Dodes & Dodes (2014) state that there are several recovery
stories are associated with AA. In most cases, success stories
are appreciated by the members of the fellowship. Such
individuals are also encouraged to look for the best ways that
help them steer clear from any alcoholic drinks. Comment by
Windows User: Remove this tentative wording from your
writing please. Comment by Windows User: Author
information should be included in the citation rather than the
title of the source.
Not all AA stories end positively. There are situations where a
member of an AA group might relapse into drinking (Dodes &
Dodes, 2014). However, they are not left to continue with the
behavior. Instead, deliberate efforts are made to ensure that they
are brought back into the circle and proper follow-up is made.
This approach ensures that their situation does not worsen. The
company that an alcoholic keeps is also one of the precursors of
a relapse into alcoholism. Consequently, it is appropriate to
motivate such individuals to avoid their drinking partners by
keeping themselves busy. This strategy would aid in keeping the
AA adherents busy during their meetings (The 12 Steps of AA
Explained, 2018). The fellowship leader took personal
responsibility of ensuring that there is total compliance to the
rules. The strategies that have been mentioned above show that
AA groups are focused on their objectives. I attended meetings
whereby I witnessed some of the points that have been
mentioned above.
This section is also incomplete. The content and research
requirements for this section have not been addressed in an
appropriate level of depth and detail based on the published
literature. Please consult the published literature and provide a

detailed summary of the group’s philosophy and model of
treatment, the types of meetings offered, service and leadership
positions, the role of sponsorship, and other basic details that
provide an overview of the organization’s model and approach.
Base these sections on the literature please.
Personal Observations of the Meetings
Attending the AA gatherings provided me with an eye-
opening opportunity into the world of alcoholism. In most
cases, people tend to ignore the cries of alcoholics, but they
might not know that the same people have tried to quit the habit
with little success. AA gives them an opportunity to redeem
themselves through the inspirational stories that other
participants share. Everyone has his or her own story to tell.
Hence, a person needs to be optimistic and work on the avenues
that might help in quitting addictive behaviors.
During my two meetings, I saw a group of determined
individuals that were willing to change for the better. The
organization of the group intrigued me. The leader made
everything look easy by coordinating all the activities. Although
most of the participants were recovering addicts, there was
minimal shouting and no violence during the sessions. This
point proves that the level of commitment of the alcoholics was
commendable considering their physical and mental disposition
at the moment. The sessions seemed therapeutic as the group
would burst in laughter once in a while as different people
shared their stories and experiences of alcoholism. I was keen
enough to grasp most of the details because I had only attended
less than five such events before. Everything was still so new to
me. However, I was attentive all through so that I could not
miss out on any information that could have helped in getting a
better understanding of the operations of Alcoholics
Anonymous.
The cooperativeness of the entire group caught my attention.
They were allowing each other time to talks without any form of
interruption in between the conversation. As a gathering of both
recovering and continuing alcoholics, someone would expect

some rowdiness. However, I saw none of such behavior.
Additionally, the politeness and sympathetic nature of the
participants was also cognizable. There were some emotional
moments, but everything was in control because the individuals
are aware of their objectives.
Another noticeable aspect involved the level of discipline
within the group. Everyone was always seated before the
meeting began. This affirms the level of commitment,
dedication, and respect that every member has in the AA
fellowship. This trend can help alcoholics recover fast so that
they can continue with their normal lifestyles. Further, such
stories aid in confirming the effectiveness of Alcoholics
Anonymous groups within society.
Conclusion
My AA experience was marvellous (?) because I came to
learn about several crucial issues. This model of treatment is
essential because it covers the disease model (Capuzzi &
Stauffer, 2016). The first step is to acknowledge that you are
powerless to the disease; it is not viewed as a moral issue of
right versus wrong (The 12 Steps of AA Explained, 2018).
Comprehending the 12 steps is essential because it aids in
making key strides towards sustainable sobriety in life.
Alcoholism is a habit that needs interventions to be solved
(Dodes & Dodes, 2014). Therefore, any alcoholic who is willing
to drop the habit can visit an open meeting for further
assistance. However, AA provides a unique format where the
participants get to share their stories, the approaches that they
are using towards quitting drinking and obtain a sponsor to
assist them on their daily walk towards sobriety (Jensen, 2000).
This technique is exceedingly therapeutic because it is
interactive, and the participants get to learn the steps that have
been applied by other people who are going through the same
life challenges.
The success rate of this model is commendable based on the fact
that it is not capital intensive (?) as other approaches (The 12
Steps of AA Explained, 2018). The AA concept would be a

crucial part of my work in the future because I have already
learned how the fellowship operates. In case I have a client,
who might be struggling with alcoholism, I would encourage
him or her to join the nearest AA group, along with weekly
psychotherapy to address underlying issues contributing to
relapse. The information that I have learned would help me in
convincing such a person about the gains of joining such an
association.
This assignment is a bit short. Please complete a minimum
length of six full pages of writing per posted instructions.
References
Capuzzi, D., & Stauffer, M. D. (2016). Foundations of
addictions counselling (3rd ed.). New
York, NY: Pearson. ISBN: 9780134280981.
Dick, B. (2007). Introduction to the Sources and Founding of
Alcoholics Anonymous. Good
Book Publishing Company.
Dodes, L. M., & Dodes, Z. (2014). The sober truth: Debunking
the bad science behind 12-
step programs and the rehab industry. Beacon Press.
Jensen, G. H. (2000). Storytelling in Alcoholics Anonymous: A
rhetorical analysis. Southern
Illinois University Press.
Author of the source is required here please. The 12 Steps of
AA Explained. (2018). Retrieved from
http://www.ashwoodrecovery.com/blog/12-steps-explained/
Experiential Papers Grading Rubric
Criteria
Levels of Achievement
Content
Advanced
Proficient

Developing
Not Present
Name/Brief History of Organization
16 to 18 points
Each of the following are thoroughly identified: Name and Brief
History of Organization (introduce what it is: AA, NA, Al-
Anon; how long has it been around; important individuals and
milestones in its development; future goals, etc.).
14 to 15 points
This section is not thorough in identifying the following: name
and Brief History of Organization (introduce what it is: AA,
NA, Al-Anon; how long has it been around; important
etc.).
1 to 13 points
Name and Brief History of Organization (introduce what it is:
etc.).
0 points
These things are not discussed.
Setup, Methodology/
Model of Treatment
16 to 18 points
Each of the following are thoroughly identified: How the
Meetings are Run/Organized (what helping model it is based on;
what the “leader’s” role is; how the group recognizes success
stories; what they do for relapses, etc.).
14 to 15 points
This section is not thorough in identifying the following: How
1 to 13 points
Two or more essential elements of this section are missing: How

0 points
These areas are not included in the paper.
Personal Observations
15 to 17 points
Each of the following are thoroughly identified: Personal
Observations of the Meetings (what I saw; what was interesting;
observations of the group members [no names]; particular
stories that caught my attention, etc.).
13 to 14 points
1 to 12 points
0 points
This is not present.
Conclusion, Good Method of Treatment
15 to 17 points
Each of the following are thoroughly identified: Conclusion
(what I learned; is it a good model of treatment; how could I use
this in my work/practice in the future, etc.).
13 to 14 points
1 to 12 points

0 points
Work settings and practice standards are not present.
Structure
Advanced
Proficient
Developing
Not Present
Mechanics
9 to 10 points
No grammar, spelling, or punctuation errors are present. Voice
and person are used correctly and consistently. Writing is
precise. Word choice is appropriate.
8 points
Few grammar, spelling, or punctuation errors are present. Voice
and person are used correctly. Writing style is sufficient. Word
choice is adequate.
1 to 7 points
Several grammar, spelling, or punctuation errors are present.
Voice and person are used inconsistently. Writing style is
understandable but could be improved. Word choice is generally
good.
0 points
Numerous spelling, grammar, or punctuation errors are present.
Voice and person are misused. Writing style is difficult to
understand. Word choice is poor.
APA Format Elements
9 to 10 points
Citations and format are in current APA style. Cover page,
citations, running head, and references are correctly formatted.
Paper is double-spaced with 1-inch margins and written in 12
point Times New Roman font. An Abstract is not needed.
8 points
Citations and format are in current APA style with few errors.
Cover page, citations, running head, and references are present

with few errors. Paper is double-spaced with 1-inch margins and
written in 12 point Times New Roman font.
1 to 7 points
Citations and format are in current APA style though several
errors are present. Cover page, citations, running head, and
references are included though several errors are present. Paper
is double-spaced, but margins or fonts are incorrect.
0 points
Citations are not formatted correctly. Cover page, running head,
and references are not included or not formatted correctly.
Paper is not double-spaced, margins are incorrect, or font is
incorrect.
Research Elements
9 to 10 points
Major points are supported by at least 3–4 scholarly sources in
addition to the course textbook. Paper is appropriate length of
6–7 pages.
8 points
Major points are supported by 1–2 scholarly sources in addition
to the course textbook. Paper is not the appropriate length and
is either excessively long or too brief.
1 to 7 points
Major points are supported by at least 1 scholarly source and
the textbook is not listed/or the resources are not scholarly.
Paper is not the appropriate length and is either excessively
long or too brief.
0 points
Major points are not supported scholarly sources. Paper is not
the appropriate length of 6–7 pages.
Total: 78/100
Instructor’s Comments: Please develop the required content
areas in an appropriate level of depth and detail that reflects a
careful and thorough interaction with the published literature.
Please be sure to consult outside reading and research and
incorporate that information into your paper.

JOURNAL OF DUAL DIAGNOSIS, 7(3), 175–185, 2011
Copyright C© Taylor & Francis Group, LLC
ISSN: 1550-4263 print / 1550-4271 online
DOI: 10.1080/15504263.2011.593418
CLINICAL FORUM
Treatment of a Young Man With Psychosis
and Polysubstance Abuse
Mary R. Woods, RN, LADAC,1 and Robert E. Drake, MD,
PhD2,3
This clinical forum presents the potential of implementing
evidence-based dual diagnosis services
in the private sector. Family members started and continue to
oversee the WestBridge program
based on a steadfast commitment to evidence-based care.
An initial case presentation describes a young man who had
repeatedly floundered in separate
mental health and addiction treatment programs but was able to
recover within an evidence-based
approach. The case represents an amalgam of several typical
program participants.
The authors describe several refinements of evidence-based
practices developed within the
program. These include a philosophy of dual recovery; a
personalized integration of mental
health, substance abuse, and physical health interventions; safe,
flexible, and recovery-oriented

housing; a multidisciplinary, community-based team; extensive
use of mentors, peer support, and
12-step meetings; family education and support; supported
education and employment; team-
based medical and medication management; and holistic
treatment.
The WestBridge model incorporates many elements of health
care reform: a medical home, in-
tegrated interventions, bundled payments for value rather than
for amount of services, participant-
centered care, commitment to information technology, and a
reduction of middle managers. Early,
intensive, evidence-based care is expensive but may lead to
prolonged recovery and substantial
cost savings over time. As such, this approach to dual diagnosis
services may be a model for
health care reform.
CASE PRESENTATION
Jon was a 25-year-old man with a history of psychosis,
hypomania, alcohol abuse, marijuana
abuse, and LSD abuse when his family contacted WestBridge.
He was under observation at
1WestBridge Community Services, Manchester, New
Hampshire, USA
2Department of Psychiatry, Dartmouth Medical School,
Lebanon, New Hampshire, USA
3Dartmouth Psychiatric Research Center, Dartmouth Medical
School, Lebanon, New Hampshire, USA
Address correspondence to Mary R. Woods, WestBridge
Community Services, 1361 Elm St., Suite 207, Manchester,
NH 03101, USA. E-mail: [email protected]

176 M. R. Woods and R. E. Drake
his hometown community hospital in a Midwestern state after
wandering into a local mall and
shouting obscenities. Since the age of 18, he had a history of
eight admissions to inpatient mental
health facilities and four admissions to inpatient addiction
programs. Testing at the time of his
current admission revealed the presence of amphetamines and
marijuana, a blood alcohol level
of 0.08, and a lithium level of 0.4. He reported taking
risperidone sporadically.
Jon’s family history included several male relatives with
alcoholism and depression on both
sides of the family. His parents were both professionals. The
family had a long-term housekeeper,
but both parents had been involved in their children’s activities.
During high school, Jon was an above-average student who
excelled in math and music. He
received a university scholarship, was majoring in accounting,
and played in the school band. His
freshman year was stressful and complicated by partying, binge
drinking, and using marijuana and
LSD. During his first summer break, he began to hear voices
coming from the television when it
was turned off. Concerned with Jon’s behavior, his family
brought him to a local psychiatrist, who
admitted Jon to an inpatient psychiatric hospital for evaluation.
Friends brought Jon marijuana
and LSD, which he used throughout his admission. His
substance use was never assessed.

Over the course of the next 2 years, Jon continued to use
alcohol and other drugs, experiencing
periods of brief psychosis, and flunked out of college. He
returned home and worked in his father’s
business, but increasing delusions and paranoia led to several
admissions to various treatment
facilities.
When the family contacted WestBridge, they were feeling
hopeless, stressed, and fearful. Jon’s
siblings were angry about his behavior, feeling that their
parents were spending too much time,
effort, and money on their brother. Jon had assaulted each of
them, had been drunk and delusional
at his sister’s wedding, and had disrupted many family
gatherings. Family therapy had not helped.
Jon was troubled by his lack of academic progress and his
paranoia, and he felt regret and shame
over his relationships with family members. Nevertheless, he
believed that his use of alcohol and
other drugs was not a problem.
The admission team explained WestBridge’s services, including
the use of several evidence-
based treatment interventions, by telephone. Two staff members
then flew to the Midwest to meet
with Jon and his family. Over the course of 2 days, they
explained the program, assessed Jon, and
answered questions.
Almost immediately, Jon’s father brought him to New
Hampshire for admission to West-
Bridge’s residential program. The team reviewed Jon’s
individual and family needs and helped
them to develop a Personal Achievement Plan that articulated

their short-term and long-term
goals. Jon’s agenda included developing skills to identify and
cope with delusions and paranoia,
improving his relationships with all his family members,
attending college, and finding a job.
Jon entered the Commons, a residential treatment agency for
adult men (aged 18 or older)
experiencing co-occurring severe mental illness and substance
use disorders. During his first
2 weeks, he received a full medical and psychosocial
assessment, achieved a therapeutic level
of lithium and risperidone, and attended groups on drug
education, coping with stress, anger
management, relapse triggers, psychoeducation, men’s issues,
illness management, and 12-step
support. He developed a Wellness Recovery Action Plan, which
he shared with his family. He
participated in cognitive behavioral therapy to learn to manage
symptoms of mental illness;
motivational interviewing to resolve his ambivalence about
drugs; daily exercise, art group, and
yoga with other residents; and weekend activities in the
community. Although unwilling to attend
community self-help groups initially, he participated in
recovery groups in the Commons. The
Journal of Dual Diagnosis
Clinical Forum 177
program internist diagnosed sleep apnea and referred Jon to a
sleep clinic, where he received a
continuous positive airway pressure (CPAP) device and a sleep

hygiene plan.
During 4 months at the Commons, Jon completed the illness
management and recovery
program and began to use new coping skills. He and his family
participated in family education
and support, in which they developed an agreement that allowed
everyone to feel safe and begin
recovering. Each family member committed to a goal: Jon’s
mother to going to the gym three
times a week, his father to practicing the piano three times a
week, his sister to taking a college
course, and his brother to joining a basketball team. They
learned to communicate effectively, to
solve problems as a family, to cope with stress, and to manage
addiction and mental illness. Jon’s
mother and father started to sleep well at night and were more
available to the other children.
Meanwhile, Jon transitioned into the community gradually over
2 weeks, spending every other
night in his apartment with the support of mentors and sleep
coaches. The Assertive Community
Treatment team followed him closely and helped him to attend
therapeutic activities that he
chose: illness management and recovery group, men’s group,
cooking skills group, coffee group
(a social group), and individual dual diagnosis counseling.
Evening mentors (described below) helped Jon with his college
classes, activities of daily
living, exercise, and attending one self-help meeting each week.
Sleep coaches helped him to
develop new sleep habits and to use his CPAP machine. Jon
volunteered at a local camp doing
landscaping and painting while attending college. He began to

identify with mentors and to
enjoy the young people’s self-help meeting, concluding that he
needed to abstain from alcohol,
marijuana, LSD, and other drugs if he was going to finish
school and have a career.
One year after entering WestBridge, Jon had completed two
college courses, was enrolled in
additional courses, was attending self-help meetings three
nights a week, had a sponsor, was work-
ing as a cashier 20 hours a week, and was managing his mental
illness, addiction, and sleep apnea.
DISCUSSION
As this clinical narrative illustrates, people with dual diagnosis
can do well when they receive
effective treatments and supports. Financial resources, personal
strengths, and familial supports
help, but evidence-based services are essential. Many people
with co-occurring disorders who
have fared poorly in non-integrated or non–evidence-based
programs are able to recover—to
manage their illnesses, to maintain abstinence, to pursue
educational and occupational goals,
and to develop positive relationships with families and peers—
when they receive integrated,
evidence-based services.
In the following discussion, we first describe several elements
of evidence-based care at
WestBridge and then consider the potential of this model for
health care reform.
Evidence-Based Practices

Interventions that are proven to be effective by rigorous
research studies are called evidence-based
practices (Institute of Medicine, 2001; New Freedom
Commission on Mental Health, 2003).
Several effective interventions for people with serious mental
illness and co-occurring substance
use disorder exist (Drake, O’Neal, & Wallach, 2008), but
current programs rarely provide these
2011, Volume 7, Number 3
services (Epstein, Barker, Vorburger, & Murtha, 2004). Even
programs that identify themselves as
dual diagnosis programs usually fail to provide the most
effective services (Drake & Bond, 2010).
What are evidence-based practices for people with co-occurring
disorders? Integrated mental
health and addiction interventions, safe housing, Assertive
Community Treatment, residential
treatment, dual diagnosis groups led by professionals, supported
employment, medications for
mental disorders and for addictions, and contingency
management are all supported by controlled
research studies (Brunette, Mueser, & Drake, 2004; Drake et al.,
2008; Mueser, Campbell, &
Drake, 2011; Tsemberis, Gulcur, & Nakae, 2004). Peer support
groups are supported by many
correlational studies (Monica, Nikkel, & Drake, 2010). Other
interventions, such as motivational
interviewing, cognitive behavioral treatment, family
interventions, strengths-based care man-

agement, sleep therapies, supported education, and trauma
treatments, are not yet supported by
rigorous research but are promising components of a
comprehensive dual diagnosis program.
The clinical details of these interventions are described in detail
in several textbooks and manu-
als (Brunette, Drake, Lynde, & the Integrated Dual Disorders
Treatment Group, 2002; Mueser,
Noordsy, Drake, & Fox, 2003; Corrigan, Mueser, Bond, Drake,
& Solomon, 2008; Swanson &
Becker, 2011; Fox et al., 2010).
One compelling feature of the WestBridge program is that
clinicians, clients, families, and
researchers have collaborated for 10 years to refine several of
these evidence-based practices. We
next describe these refinements and how they are combined and
individualized.
Philosophy
WestBridge combines evidence-based practices with an overall
philosophy of dual recovery,
optimism, strengths, shared decision making, and harm
reduction, consistent with concepts in the
literature for many years but rarely realized in actual practice
(Minkoff, 1989; Ridgely, Goldman,
& Willenbring, 1990; Carey, 1996; Mueser et al., 2003; Fox et
al., 2010). Clients and families are
encouraged to develop realistic recovery goals that address
illness self-management, safe housing,
respectful interactions with family members, peer friendships
that do not involve substances of
abuse, physical wellness, and mainstream education and
employment. Participants identify their
own specific goals, actively choose interventions, and develop

their own recovery plans within a
process of shared decision making that involves transparency,
access to the most recent scientific
information, and personal preferences (Mueser & Drake, in
press).
The program’s optimistic philosophy regarding dual recovery is
bolstered by evidence that
most people do recover from dual disorders (Drake, Xie,
McHugo, & Shumway, 2004; Drake
et al., 2006). Recovery occurs in several domains, in different
sequences, at different times, and
following various pathways (Xie, McHugo, Sengupta, & Drake,
2003; Xie, Drake, & McHugo,
2006; Xie, Drake, McHugo, Xie, & Mohandas, 2010). Early
intervention and evidence-based
practices facilitate recovery by helping people to recover at a
faster pace and preventing the most
serious adverse consequences of illness (McGorry, Killackey, &
Yung, 2010).
Integration
Service integration entails combining and individualizing
interventions for mental health,
addiction, physical health, and psychosocial functioning for
people who have dual disorders. The
Clinical Forum 179
client and family participate in identifying goals and preferred
interventions, but the clinical team

takes responsibility for integrating these interventions into a
coherent package. Integration affects
all aspects of care. For example, medication management
addresses not just symptom control
but also interactions with abused drugs, side effects, and
physical health. Family education
and support encompass mental illness, addiction, co-occurring
disorders, physical wellness, and
psychosocial issues. Supported education and employment help
people to find school programs
and jobs of their choice in regular community environments that
are supportive and free of
addictive behavior. Social skills training targets making friends
who are abstinent, avoiding drug
purveyors, and maintaining a healthy lifestyle.
The evidence for mental health and addiction service integration
is robust (see Drake, Mueser,
Brunette, & McHugo, 2004; Drake et al., 2008; Dixon et al.,
2010 for reviews). People with
multiple needs have difficulty participating in fragmented, non-
integrated services; attending
many programs and making sense of divergent messages from
various sources confuse people
and lead to poor access or disengagement. Combining services
in one multidisciplinary team is
more efficient, practical, and effective. Research consistently
shows that integrated services are
more effective than non-integrated services.
Housing
Within the overall philosophy of dual recovery, safe, flexible,
recovery-oriented housing is
a cornerstone (Alverson, Alverson, & Drake, 2000). The
WestBridge approach to housing is

unique but consistent with the evidence. Participants who need
stabilization begin their expe-
rience at the Commons, a residence for 10 to 12 men where they
learn about dual diagnosis,
stop using substances, achieve symptom control with a minimal
medication regimen, become
acculturated to 12-step philosophy, and bond with other
participants, mentors, and staff members.
Need rather than insurance coverage determines length of stay
at the Commons, but clients are
encouraged to transition rapidly to independent living, usually
within 2 or 3 months, with as
much support as needed. Relapses or other difficulties can
occasion a return to the Commons for
whatever time is needed to get back on a recovery track.
Movement toward independent living
is rapid, individualized, strongly supported by staff, and
flexible in pace. Participants do not
remain in or move to supervised group homes; instead,
Assertive Community Treatment teams
provide outreach and support to independent living settings.
Participants are not dismissed from
housing or the program because of a relapse. Some do leave the
area to return to college or to
their hometowns, but most stay nearby in independent housing
to complete college or pursue
careers.
The evidence for safe housing and flexible transitions to the
community is extensive, although
the specific types of housing arrangements vary extensively
(Tsemberis et al., 2004; Brunette
et al., 2004; McHugo et al., 2004). One consistent finding is
that transitions from residential
treatment to the community should be gradual and flexible,
allowing for movement back and

forth with supports as needed. In most studies successful
residential treatment lasts for at least
9 months (Brunette et al., 2004). The WestBridge experience
shows, however, that residential
treatment can be much briefer if transitions to independent
living are flexible and supports are
generous.
Assertive Community Treatment
A multidisciplinary team engages clients in the community
using outreach, support, moti-
vational interviewing, and other techniques. The team provides
treatment and support in the
community 24 hours per day, 7 days a week. The team includes
care managers, a vocational spe-
cialist, a nurse, an addiction counselor, a part-time psychiatrist
and internist, and a team leader.
Mentors (described below) are also part of the team. Daily
meetings and frequent electronic com-
munications allow the team to individualize and coordinate
services. Motivational interviewing
helps clients to work through ambivalence around sobriety,
taking medications, and pursuing
meaningful goals.
Assertive Community Treatment enables people with multiple
difficulties to maintain stable
housing and to avoid hospitals and homeless settings (Mueser,
Bond, Drake, & Resnick, 1998).

The multidisciplinary team incorporates dual diagnosis
treatments, supported employment, and
other evidence-based interventions.
Peer Support, 12-Step Meetings, and Mentors
Young people are of course intensely interested in relationships
with peers, and these influences
can impede or facilitate recovery. At the Commons, the young
men participate together in several
discussion groups each day, attend Alcoholics Anonymous (AA)
and other 12-step meetings
together, go to the gym and to other activities together, and
make plans for school, work, and
independent housing together. The net result is that they support
each other’s recoveries.
AA and other 12-step groups can provide peer support,
education, optimism, mentors, spiritu-
ality, coping strategies, and other supports for recovery.
Participants at WestBridge are introduced
to the 12-step philosophy through discussion groups,
interactions with staff, and attending meet-
ings in the community. In addition, mentors, who may be AA
members with long-term sobriety
or people who have been educated and oriented to self-help
programs, are employed to help
participants with evening activities, including but not limited to
attending 12-step groups. The
mentoring program enables a large proportion of participants to
find role models and to connect
with the AA fellowship. For many participants, friendly support
for AA attendance and oppor-
tunities to discuss the principles and steps of AA with a mentor
may be necessary to facilitate
connections with 12-step groups.

The evidence for 12-step involvement among people with co-
occurring disorders is mixed.
Some studies have found limited involvement (Noordsy,
Schwab, Fox, & Drake, 1996), but several
others have found that involvement nevertheless correlates with
recovery (Monica et al., 2010).
The critical difference may be explained by some combination
of introduction procedures, support
for attendance, and the availability of programs that are
modified for people with co-occurring
disorders, such as Dual Diagnosis Anonymous.
In addition, professionally led peer groups are effective in
controlled trials of dual diagnosis
treatments (Drake et al., 2008). The finding that different types
of groups are effective across
these trials suggests that common elements, such as peer
support, are more important than any
particular model of intervention.
Clinical Forum 181
Family Education and Support
Many WestBridge participants have had difficult and even
fractured family relationships
before entering the program. Learning to communicate clearly
without acrimony and develop-
ing positive family supports are therefore important aspects of
recovery for many people. All
families participate in weekly family education and support

meetings, usually via conference
calls. Family members and participants frequently report an
increase in support, understanding,
and optimism.
Evidence for the effectiveness of family education and support
is abundant in both the addiction
and serious mental illness fields but is just emerging in the dual
diagnosis field. Longitudinal
evidence confirms the importance of family support for dual
diagnosis clients (Clark, 2001).
One randomized controlled trial included family
psychoeducation in a successful intervention
package (Barrowclough et al., 2001).
Supported Education and Employment
Recovery involves pursuing activities that provide structure,
social contacts, and meaning-
ful roles. For most adults in the United States, meaningful roles
in society include education
and competitive employment. Supported education and
employment are therefore essential for
people with dual diagnosis. All participants at WestBridge plan
for functional recovery from
the beginning of treatment, and the great majority are working
and/or going to school within 6
months.
Supported employment consistently helps approximately two-
thirds of people with dual di-
agnosis to obtain competitive employment (Sengupta, Drake, &
McHugo, 1998; Mueser et al.,
2011). Although dual diagnosis clients are often screened out of
vocational services (Frounfelker,
Wilkniss, Bond, Devitt, & Drake, 2011), they do as well as

single diagnosis clients when they
access services. Younger clients are of course interested in
education as well as employment;
supported education and supported employment services can be
combined effectively by the
same specialists (Nuechterlein et al., 2008; Rinaldi et al., 2010).
Abstinence is not a prerequi-
site for supported employment; the evidence shows instead that
employment typically precedes
abstinence and probably motivates clients to stop using alcohol
and drugs (Xie et al., 2010).
Medication and Medical Management
WestBridge provides a nurse, a psychiatrist, and an internist to
integrate psychiatric and medical
care with rehabilitation and recovery. A full-time nurse on the
team optimizes the role of doctors
and facilitates daily check-ins regarding medications and side
effects. Because perverse insurance
regulations and payments are not involved, the nurse can be
constantly available by e-mail and
telephone. Daily monitoring and intensive supports allow the
team to avoid polypharmacy, to use
clozapine optimally, to offer medications for addiction to those
who are interested, and to avoid
addictive medications and dangerous interactions.
Evidence for the effectiveness of psychotropic medications is of
course extensive. At the

same time, research shows that many people with complex
disorders are vulnerable to over-
medication, polypharmacy, and cumulative side effects
(NASMHPD Medical Directors, 2001).
People with psychosis, especially those with co-occurring
substance use disorders, are unlikely
to receive appropriate clozapine trials and addiction
medications and are likely to be overpre-
scribed opiates, benzodiazepines, and sleep medications
(Brunette, Noordsy, Xie, & Drake, 2003).
Systematic medication management following evidence-based
algorithms and standardized as-
sessments avoids all of these errors (Miller et al., 2004).
Holistic Treatment
Dual diagnosis is often a misnomer because most people with
serious mental illness and
substance use disorder have multiple challenges. In addition to
dual diagnoses, they may, for
example, have trauma histories, learning disabilities, legal
entanglements, pain syndromes, sleep
disorders, and other issues that impede recovery and require
attention. Effective treatment com-
bines interventions for all relevant conditions into a coherent
package of holistic treatment.
The evidence for holistic treatment of this type is minimal
because such services are rarely
provided, are idiosyncratically complex, and have not been
studied. Perhaps the best evidence for
integrating multiple interventions is the extensive research on
Assertive Community Treatment
(Mueser et al., 1998).
Health Care Reform

Some might argue that private dual diagnosis treatment, other
than refining specific components
of care, has minimal relevance for the public sector and for
health care reform. An opposing
view asserts that private treatment may offer models for health
care reform. The WestBridge
approach, for example, incorporates many elements of proposed
health care reforms (Agency for
Healthcare Research and Quality, 2011; Bielaska-DuVernay,
2011; Cutler, 2004; Fowler, Levin,
& Sepucha, 2011; Gao et al., 2011; Institute of Medicine, 2001;
New Freedom Commission on
Mental Health, 2003; U.S. Department of Health and Human
Services, 2011). Families pay for
value, represented by recovery, rather than for amounts of
services. Multidisciplinary teams offer
a medical home by coordinating and integrating physical and
behavioral health care. Interventions
are completely client-centered; clients and families negotiate
their goals up front using shared
decision making, and the model emphasizes self-management
from the beginning. WestBridge is
developing information systems to insure that research findings,
treatment plans, and outcomes
are transparent. Independence and use of community resources,
rather than dependence on the
mental health system, are primary goals. Insurance companies,
regulators, and other middle
managers are largely eliminated from the picture.
Is the cost of private dual diagnosis care really prohibitive?
Research increasingly demonstrates
that early and intensive use of effective interventions may
actually save health care costs over
the long run (see, e.g., Jacobson, Mulick, & Green, 1998;

Gatchel et al., 2003; Banerjee &
Wittenberg, 2009). For people with complex co-occurring
disorders, evidence-based treatment
Clinical Forum 183
may prevent years of disability, high health care utilization,
incarceration, community costs, and
human costs. Economic modeling may show that over the long
run, costs for evidence-based care
are lower than for ineffective care. The hypothesis merits
careful study.
DISCLOSURES
Ms. Woods and Dr. Drake report no financial relationships with
commercial interests with regard
to this manuscript. Dr. Drake serves as a consultant to
WestBridge Community Services.
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JOURNAL OF DUAL DIAGNOSIS, 7(1–2), 4–13, 2011
ISSN: 1550-4263 print / 1550-4271 online
DOI: 10.1080/15504263.2011.568306
PSYCHOTHERAPY & PSYCHOSOCIAL ISSUES
Dual Diagnosis in an Aging Population: Prevalence
of Psychiatric Disorders, Comorbid Substance Abuse,
and Mental Health Service Utilization in the Department
of Veterans Affairs
Karin E. Kerfoot, MD, Ismene L. Petrakis, MD, and Robert A.
Rosenheck, MD
Objective: In the context of an aging baby boom cohort with
higher rates of substance use disorders
than previous cohorts, the abuse of substances and dual
diagnosis represent growing areas of concern
among older adults. The aims of this study were to determine
the current treated prevalence of major
psychiatric illnesses, substance use disorders, and dual
diagnosis across multiple age groups in a
national sample of mental health patients and to examine
associated service utilization. Methods:
Using administrative data from specialty mental health clinics
in the Department of Veterans Affairs
(N = 911,725), treated prevalence of major psychiatric illnesses,
substance use disorders, and dual
diagnosis across multiple age groups were determined over a 1-

year interval (FY 2009). Associated
mental health service utilization was examined. Results: Treated
prevalence of almost all major
psychiatric and substance use disorders decreased with age,
while dementias increased with age.
Across all major psychiatric illnesses, documented comorbid
substance abuse decreased with age.
Those with dual diagnoses had higher utilization of outpatient
services compared to those without
substance use disorders. With older age, patients had fewer
outpatient visits and reduced likelihood
of psychiatric hospitalization, but incurred more inpatient days
per episode. Conclusions: Treated
prevalence of substance use disorders and dual diagnosis
decreases with age, falling to approximately
10% in those older than 65. Questions remain regarding the
possibility of underdiagnosis of substance
use disorders in the elderly. (Journal of Dual Diagnosis, 7:4–13,
2011)
Keywords dual diagnosis, co-occurring, concurrent, substance
abuse, older adult, geriatrics,
veterans, health service use
This article is not subject to U.S. Copyright law.
All authors are affiliated with the Department of Psychiatry,
Yale University, New Haven, Connecticut, USA.
Address correspondence to Karin E. Kerfoot, MD, West Haven
Veterans Affairs Medical Center #116-A, 950 Campbell
Ave., West Haven, CT 06516, USA. E-mail: [email protected]
Dual Diagnosis in an Aging Population 5

Older adults comprise a dramatically growing and changing
group within the American popula-
tion. By 2030, the number of Americans aged 65 and older is
expected to be twice as large as
in 2000, growing from 35 million to 72 million, and
representing nearly 20% of the total U.S.
population (Federal Interagency Forum on Aging-Related
Statistics, 2010). This segment will be
increasingly composed of baby boomers, born between 1946 and
1964 (and first reaching age
65 in 2011). Given that this cohort has reported higher lifetime
rates of drug and alcohol
use and is significantly larger than previous cohorts, it has been
anticipated that both substance use
and comorbid substance use with psychiatric disorders will be
growing areas of concern among
older adults as they “age in” to geriatric status (Colliver,
Compton, Gfroerer, & Condon, 2006;
Gfroerer, Penne, Pemberton, & Folsom, 2003). Patients with
both psychiatric and substance use
disorders present unique challenges to psychiatric practice
because this combination of disorders
tends to adversely impact the course and severity of illness and
retention in treatment (Gonzalez
& Rosenheck, 2002).
Data collected in the 1980 Epidemiological Catchment Area
study showed that substance use
and mental health disorders, on their own, are significantly
prevalent in the elderly. The 1-month
prevalence for any psychiatric disorder among individuals aged
65 years and older was 12.3%
(Regier et al., 1988). Most common in this age group were
anxiety disorders (5.5%) and severe
cognitive impairment (4.9%), while 0.9% met criteria for
alcohol abuse/dependence at the time

of the survey, some 30 years ago. Results from the 2001–2002
National Epidemiologic Survey on
Alcohol and Related Conditions (N = 43,093) of the general
U.S. population revealed that 2.4%
of older (65 years or older) men and 0.4% of older women (65
years or older) met diagnostic
criteria for 12-month prevalence of alcohol abuse (Grant et al.,
2004). In the mid-1990s, a survey
of primary care patients reported a point prevalence of 31.7% of
patients aged 60 years and older
(N = 224) with at least one active psychiatric condition, while
4.5% of men and 0.8% of women
had active alcohol abuse or dependence (Lyness, Caine, King,
Cox, & Yoediono, 1999).
Prevalence of substance use disorders and concurrent
psychiatric illness is not surprisingly
much higher in mental health care settings. A University of
Virginia geriatric psychiatry outpatient
clinic sample (60 years and older; N = 140) found 20% to have
a current substance use disorder:
11.4% with benzodiazepine dependence and 8.6% with alcohol
dependence (Holroyd & Duryee,
1997). Of these, 93% had comorbid psychiatric illness. A
second study of three private psychiatric
inpatient settings showed that 37.6% of older inpatients (65
years or older) had dual diagnoses:
71% with alcohol abuse and 29% with both alcohol and other
substance abuse (Blixen, McDougall,
& Suen, 1997). A recent review examining dual diagnosis in the
elderly highlighted not only the
high prevalence of comorbid substance abuse and mental
disorders in older adults, depending on
the population, but also the association with increased
suicidality and greater service utilization,
in both inpatient and outpatient samples (Bartels, Blow, van

Citters, & Brockmann, 2006).
A previous Veterans Affairs (VA) study (N = 91,752) examined
the prevalence of dual
diagnosis and service use among mental health program patients
in fiscal year 1990 and found
that the percentage of veterans with dual diagnoses declined
significantly and steadily with age,
dropping from 30.4% of those younger than 55 to 4.4% of
veterans aged 75 and older (Prigerson,
Desai, & Rosenheck, 2001). Patients were then split into two
age groups, with those aged
55 years and older referred to as “elderly” and those younger
than 55 years designated as “non-
elderly.” The elderly with dual diagnoses had longer inpatient
stays for substance abuse and more
outpatient substance abuse visits than did the elderly without
dual diagnoses. Furthermore, elders
with dual diagnoses had more outpatient general psychiatric
visits than other contrast groups, but
2011, Volume 7, Numbers 1–2
6 K. E. Kerfoot et al.
comparisons across specific psychiatric diagnoses were not
reported. While it was concluded that
dual diagnosis appeared less common among older patients,
their heavy use of certain services
(particularly outpatient) could represent an increasing burden if
more patients with dual diagnoses
survived to old age. It was noted that one explanation for the
relatively low prevalence of dual
diagnosis in later life may be selective mortality.

Understanding the prevalence of substance use disorders among
patients with psychiatric
comorbidity is important in order to assess psychiatric needs
and plan for expanding integrated
psychiatric and substance abuse treatment services (Drake et al.,
2001) among the growing
number of elders. In the context of an aging baby boom cohort,
understanding the needs of an
older population of substance abusers is particularly relevant.
The aims of this study were to
determine the treated prevalence of major psychiatric illnesses,
substance use disorders, and dual
diagnosis specific to each psychiatric illness across multiple age
groups in a national sample of
VA mental health service users and to examine mental health
service utilization within these
groups.
METHODS
Sample and Sources of Data
Data were derived from a registry of all patients treated in
specialty mental health programs
nationally in the U.S. Department of VA during a 1-year
interval (October 1, 2008–September
30, 2009). The registry was compiled from the Outpatient Care
File and the Outpatient Encounter
File (national databases of information concerning all outpatient
services delivered in the VA) and
the Patient Treatment File, which compiles discharge abstracts
on all episodes of VA inpatient
care. All veterans who had at least one specialty mental health
visit or at least one bed day of
inpatient care in a psychiatric hospital program were included in

the analysis (N = 911,725). The
study was approved for a waiver of informed consent by the
institutional review board at the VA
Connecticut Healthcare System and Yale University in full
conformance with the Declaration of
Helsinki.
Measures
Data were available on age and diagnoses in the following
subcategories: Dementia/Alzheimer’s
Disease (290.00–290.99, 294.10, 331.00), Alcohol
Abuse/Dependence (303.xx, 305.00), Drug
Abuse/Dependence (292.01–292.99, 304.xx, 305.20–305.99),
Schizophrenia (295.xx), Bipolar
Disorder (296.0x, 296.1x, 296.40–296.89), Major Affective
Disorder (296.2–296.39), Other De-
pression (300.4x, 296.9x, 311.xx, 301.10–301.19),
Posttraumatic Stress Disorder (309.81), Anx-
iety Disorders (300.xx excluding 300.4), Adjustment Disorder
(309.xx excluding 309.81), and
Personality Disorders (301.0x, 301.2x–301.99). Outpatient
psychiatric and substance abuse spe-
cialty care visits and inpatient bed days of care in mental health
programs were identified by
standardized VA clinic codes and inpatient bed section codes
(specific codes available on request).
A dichotomous variable was created to identify those who had a
diagnosis of a substance use
disorder, defined as individuals who had at least one outpatient
encounter or bed day with an

alcohol- or drug-related diagnosis. Data on patient
characteristics such as sex, race, marital status,
and income were also derived from the VA workload databases.
Analyses
To examine the characteristics, diagnoses, and mental health
service utilization of this population,
older age groups were created as follows: 55 to 64 years, 65 to
74 years, 75 to 84 years, and 85 to
94 years. For purposes of comparison, a grouping of younger
adult veterans, aged 35 to 54 years,
was also created. For each age group, demographic
characteristics were examined, including
sex, race, marital status, and mean income. Treated prevalence
of major psychiatric disorders
and substance use disorders were determined across age groups.
Treated prevalence of clinically
diagnosed comorbid substance use disorders, within major
psychiatric illnesses and across age
groups, were then determined. Mental health service utilization,
across age groups and in veterans
with and without comorbid substance use diagnoses, was
examined. Categorical service use
variables consisted of (a) use of any general psychiatric
outpatient services, (b) use of any
substance abuse outpatient services, and (c) use of any mental
health inpatient care. Continuous
service use variables consisted of (a) number of outpatient
visits (in total and separately for general
psychiatric and substance abuse treatment) and (b) number of
psychiatric inpatient bed days of
care, for those patients with any such days. Because this study
dealt with an entire population

(veterans who use VA services), inferential statistics did not
have relevance to the analysis.
RESULTS
A total of 911,725 VA patients aged 35 to 94 years were
identified as having received VA mental
health care in FY 2009. As shown in Table 1, the largest group
was between the ages of 55 and
64 years (44.5%). Nearly 35.6% of the population was 35 to 54
years old, while 10.4% were
65 to 74 years, 7.3% were 75 to 84 years, and 2.3% were 85 to
94 years. The population was
predominantly male (92.1%), which is consistent with the
composition of the veteran population.
Much of the data on race were unknown (60.9%), although
26.6% were identified as White, 9%
as Black, and 3.2% as Hispanic. Marital status varied
significantly with age, with older patients
more likely to be married or widowed. Average income was
lowest among the youngest age
group, although large standard deviations were present in all
groups.
As seen in Table 2, the percentage of veterans with diagnosed
alcohol and other substance use
disorders decreased significantly and monotonically with age,
as did diagnoses of schizophrenia,
major depressive disorder, and personality disorders. The
highest treated prevalence of post-
traumatic stress disorder (52.9%) was seen in the 55 to 64 years
age group (consistent with
the age range of Vietnam-era veterans). As expected, organic
brain syndrome (encompassing
Alzheimer’s disease and other etiology-specific dementias) was
diagnosed more frequently with

increasing age, reaching a maximum treated prevalence of
23.5% among those 85 to 94 years
old. “Other psychiatric illnesses” (which encompassed most
additional psychiatric diagnoses not
already presented in Table 2) also showed increasing prevalence
with advancing age. The three
most prevalent diagnoses in this category were mood disorder
due to a general medical condition,
dementia not otherwise specified, and cognitive disorder not
otherwise specified.
TABLE 1
Sample Characteristics
35–54 Years 55–65 Years 65–74 Years 75–84 Years 85–94
Years 35–94 Years
(n = 324,311) (n = 405,459) (n = 94,878) (n = 66,449) (n =
20,608) (N = 911,725)
% of sample 35.6 44.5 10.4 7.3 2.3 100.0
Sex (%)
Male 84.4 95.8 97.0 98.3 95.9 92.1
Female 15.6 4.2 3.0 1.7 4.1 7.9
Ethnicity (%)
White/Caucasian 19.4 27.9 34.6 38.5 38.6 26.6
Black/African American 10.6 9.0 6.9 5.2 3.7 9.0
Hispanic 2.4 3.3 3.8 5.0 3.7 3.2
Other 0.3 0.5 0.4 0.4 0.6 0.3

Unknown 67.3 59.3 54.3 50.9 53.4 60.9
Marital Status (%)
Married 36.5 50.9 56.3 63.9 60.0 47.5
Divorced 32.4 30.5 25.9 13.9 7.7 29.0
Never married 27.8 14.7 10.8 7.1 4.5 18.1
Widowed 1.5 3.1 6.3 14.5 26.7 4.2
Unknown 1.8 0.8 0.7 0.6 1.1 1.2
Mean income (SD) 18,163
(26,556)
26,782
(44,833)
29,555
(59,757)
29,979
(65,089)
28,553
(61,329)
23,014
(42,057)
Note. Mean income is given in U.S. dollars.
Percentages of patients with specific major psychiatric illnesses
who also received a diagnosis
of a co-morbid substance use disorder are presented in Table 3.
In all diagnostic categories,
comorbid substance use disorders were diagnosed less
frequently in older adults. Co-occurring
substance use disorders were diagnosed most commonly among

veterans with personality disor-
ders (47.8%) and least frequently among those with organic
brain syndrome (6.6%).
Table 4 details mental health service utilization among veterans
in each age group. Approxi-
mately 97% of the sample used any general psychiatric
outpatient services, with percentages only
slightly increasing with age. Older patients utilizing general
psychiatric outpatient services were
significantly less likely to be documented as having received
treatment for a comorbid substance
use disorder, reaching a low of 2.2% among the oldest age
group.
Use of any outpatient substance abuse treatment declined
significantly with age, dropping
from 20.3% among 35- to 54-year-olds to 1.1% among 85- to
94-year-olds. Interestingly, among
patients who attended outpatient substance abuse visits, the
older groups were less likely to
have received treatment for a documented substance use
disorder. For example, 93.3% of 35- to
54-year-olds attending outpatient substance use visits had a
documented substance use disorder,
while only 59% of 85- to 94-year-olds attending outpatient
substance use visits were actually
documented as having a substance use disorder. The likelihood
of psychiatric hospitalization
declined significantly with age, as did the documented treatment
of a comorbid substance use
disorder among hospitalized patients.
On average, veterans with diagnosed substance use disorders
had significantly more outpatient
general psychiatric and substance abuse visits than those

without such disorders, across all age
categories (see Table 4). Mean outpatient service utilization,
measured as numbers of services
TABLE 2
Age Distributions of Clinical Diagnostic Frequencies Among
VA Mental Health Service Users
Years
(n = 324,311) (n = 405,459) (n = 94,878) (n = 66,449) (n =
20,608)
Alcohol use disorder
n = 180,756 (19.8%) 86,961 (26.8%) 78,836 (19.4%) 11,385
(12%) 3,173 (4.8%) 401 (2%)
Other substance use disorder
n = 148,001 (16.2%) 85,737 (26.4%) 56,226 (13.9%) 4,816
(5.1%) 1,044 (1.6%) 178 (0.9%)
Any substance use disorder
n = 245,154 (26.9%) 122,078 (37.6%) 104,755 (25.8%) 13,837
(14.6%) 3,923 (5.9%) 561 (2.7%)
Organic brain syndrome
n = 22,076 (2.4%) 519 (0.2%) 2,691 (0.7%) 3,709 (3.9%)
10,309 (15.5%) 4,848 (23.5%)
Schizophrenia
n = 79,018 (8.7%) 33,640 (10.4%) 33,313 (8.2%) 7,681 (8.1%)
3,671 (5.5%) 713 (3.5%)
Bipolar disorder
n = 84,198 (9.2%) 43,349 (13.4%) 29,522 (7.3%) 7,681 (8.1%)

3,119 (4.7%) 527 (2.6%)
Major depressive disorder
n = 206,776 (22.7%) 80,944 (25%) 90,552 (22.3%) 20,784
(21.9%) 11,742 (17.7%) 2,754 (13.4%)
Other depression
n = 425,508 (46.7%) 160,930 (49.6%) 183,455 (45.3%) 43,848
(46.2%) 29,189 (43.9%) 8,086 (39.2%)
Posttraumatic stress disorder
n = 359,137 (39.4%) 94,194 (29%) 214,615 (52.9%) 27,834
(29.3%) 16,892 (25.4%) 5,602 (27.2%)
Anxiety disorder
n = 221,549 (24.3%) 88,098 (27.2%) 89,031 (22%) 23,845
(25.1%) 16,026 (24.1%) 4,549 (22.1%)
Adjustment disorder
n = 93,203 (10.2%) 43,446 (13.4%) 33,095 (8.2%) 8,627 (9.1%)
6,164 (9.3%) 1,871 (9.1%)
Personality disorder
n = 35,469 (3.9%) 19,734 (6.1%) 12,818 (3.2%) 1,962 (2.1%)
787 (1.2%) 168 (0.8%)
Other psychiatric diagnosis
n = 204,645 (22.5%) 72,823 (22.5%) 77,731 (19.2%) 22,550
(23.8%) 22,930 (34.5%) 8,611 (41.8%)
received, decreased significantly in older age groups. In
contrast, average inpatient days per
year among those hospitalized tended to increase with age,
among both veterans with diagnosed
substance use disorders and those without. Substance users in
all age groups had lower inpatient
utilization than those without documented substance use
disorders.
DISCUSSION
The results of this study suggest that among veterans accessing
mental health care services in

the VA healthcare system nationally, (a) the treated prevalence
of almost all major psychiatric
and substance use disorders decrease with age, while dementias
increase with age; (b) across all
major psychiatric illnesses, documented comorbid substance
abuse decreases with age; (c) those
with dual diagnoses have higher utilization of outpatient
services, compared to those without
substance use disorders; and (d) in older age groups, patients
generally have fewer outpatient
visits and reduced likelihood of psychiatric hospitalization, but
incur more inpatient bed days of
care per year.
TABLE 3
Prevalence of Clinically Diagnosed Comorbid Substance Use
Disorders by Psychiatric Diagnosis Within
Age Groups
Years
(n = 324,311) (n = 405,459) (n = 94,878) (n = 66,449) (n =
20,608)
Organic brain syndrome
n = 22,076 (2.4%) 163 (31.4%) 499 (18.5%) 308 (8.3%) 384
(3.7%) 98 (2%)
Schizophrenia
n = 79,018 (8.7%) 12,136 (36.1%) 8,258 (24.8%) 816 (10.6%)

162 (4.4%) 15 (2.1%)
Bipolar disorder
n = 84,198 (9.2%) 19,002 (43.8%) 9,155 (31%) 1,235 (16.1%)
214 (6.9%) 21 (4%)
Major depressive disorder
n = 206,776 (22.7%) 27,599 (34.1%) 23,348 (25.8%) 2,916
(14%) 757 (6.5%) 70 (2.5%)
Other depression
n = 425,508 (46.7%) 61,229 (38.1%) 29,936 (27.2%) 6,327
(14.4%) 1,713 (5.9%) 206 (2.6%)
Posttraumatic stress disorder
n = 359,137 (39.4%) 29,449 (31.3%) 47,925 (22.3%) 3,393
(12.2%) 772 (4.6%) 91 (1.6%)
Anxiety disorder
n = 221,549 (24.3%) 30,985 (35.2%) 22,450 (25.2%) 3,074
(12.9%) 853 (5.3%) 110 (2.4%)
Adjustment disorder
n = 93,203 (10.2%) 15,464 (35.6%) 9,105 (27.5%) 1,124 (13%)
336 (5.5%) 45 (2.4%)
Personality disorder
n = 35,469 (3.9%) 10,912 (55.3%) 5,442 (42.5%) 493 (25.1%)
100 (12.7%) 10 (6%)
Other psychiatric diagnosis
n = 204,645 (22.5%) 32,571 (44.7%) 25,058 (32.2%) 3,935
(17.5%) 1,456 (6.4%) 247 (2.9%)
Treated prevalence of substance use disorders and dual
diagnosis continue to decline with age
among veterans. These patterns are consistent with previous
findings in the general population
(Grant et al., 2004) and clinical populations (Prigerson et al.,
2001). Despite this, the numbers
are still considerable, particularly in the context of an
increasingly large geriatric population. In
comparison to the relatively extensive literature on co-occurring
disorders in younger adults, little

attention has been given to the published characterization,
outcomes, and treatment of concurrent
disorders in older age (Bartels et al., 2006). Although
projections have been offered, the actual
impact of aging baby boomers on this area remains largely
unknown.
Interestingly, among older veterans who utilized outpatient
substance abuse services, increas-
ingly fewer patients actually received substance use disorder
diagnoses. It is possible that these
patients had a more distant history of substance use disorders
(now in longstanding remission) but
continued to access services in order to prevent relapse without
receiving a recorded diagnosis. It
is also possible that despite being seen in substance abuse
clinics, a substance-related diagnosis
was not recorded because clinicians were reluctant to add a new
substance-related diagnosis to
an older veteran’s chart, diagnostic criteria were not met, or the
relevant diagnosis was simply
not recorded.
One explanation for some component of the declining patterns
seen in this study may be
early mortality. The concurrence of psychiatric illness with
substance abuse is associated with
vulnerability to premature death. Disordered substance use
comorbid with mental illness is likely
to shorten life expectancy, thereby selectively removing
individuals with dual diagnoses from
older age groups.

TA
B
L
E
4
S
e
rv
ic
e
U
til
iz
a
tio
n
W
ith
in
A
g
e
G
ro

u
p
s
A
m
o
n
g
V
A
M
e
n
ta
lH
e
a
lth
P
a
tie
n
ts
in
F
Y
2

0
0
9
35
–5
4
Y
ea
rs
55
–6
5
Y
ea
rs
65
–7
4
Y
ea
rs
75
–8
4
Y

ea
rs
85
–9
4
Y
ea
rs
(n
=
32
4,
31
1)
(n
=
40
5,
45
9)
(n
=
94
,8

78
)
(n
=
66
,4
49
)
(n
=
20
,6
08
)
A
ny
ge
ne
ra
l
ps
yc
h
vi

si
ts
31
1,
59
7(
96
.1
%
)
39
4,
54
4
(9
7.
3%
)
92
,5
92
(9
7.
6%

)
65
,4
41
(9
8.
6%
)
20
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39
(9
8.
8%
)
T
re
at
m
en
t
fo
r
co

m
or
bi
d
su
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ta
nc
e
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so
rd
er
s
11
0,
33
8
(3
5.
4%
)

95
,0
38
(2
4.
1%
)
11
,9
95
(1
3%
)
3,
36
5
(5
.1
%
)
45
0
(2
.2

%
)
A
ny
su
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ab
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ts
65
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(2
0.
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)
44
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14
(1
0.
9%
)
5,
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0
(6
%
)
1,
40
2
(2
.1
%
)
23
4
(1
.1
%
)

T
re
at
m
en
t
fo
r
co
m
or
bi
d
su
bs
ta
nc
e
us
e
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so
rd
er

s
61
,2
89
(9
3.
3%
)
39
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32
(8
9.
6%
)
4,
69
5
(8
3.
2%
)
98
4

(7
0.
2%
)
13
8
(5
9%
)
A
ny
in
pa
ti
en
t
us
e
28
,3
04
(8
.7
%

)
19
,0
95
(4
.7
%
)
3,
49
1
(3
.7
%
)
2,
03
6
(3
.1
%
)
57
2

(2
.8
%
)
T
re
at
m
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t
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r
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m
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bi
d
su
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ta
nc
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e

di
so
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s
21
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64
(7
7.
6%
)
12
,5
57
(6
5.
8%
)
1,
49
0
(4
2.

7%
)
37
8
(1
8.
6%
)
45
(7
.9
%
)
G
en
er
al
ps
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vi
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N

o
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ub
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ce
8.
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(0
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(0
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6.
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(0
.0
7)
5.
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(0

.0
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4)
[C
ov
ar
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te
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(S
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)]
S
ub

st
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ce
14
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(0
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6)
11
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(0
.0
6)
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11

There is also likely to be underrecognition of substance use
disorders among the elderly.
Underdiagnosis is thought to occur more frequently in the
elderly for several reasons (Culberson,
2006a). First, there may be societal reluctance to give older
people a diagnosis that is perceived as
pejorative. Second, visible consequences of substance abuse,
such as falls or confusion, may be
attributed to comorbid medical illnesses or aging itself. Third,
there may be a false assumption that
the onset of substance use disorders rarely occurs late in life,
although it has been increasingly
recognized that disruptive life events, such as retirement or
death of a spouse, may trigger
new-onset substance misuse in later life (Rigler, 2000). Finally,
the DSM diagnostic criteria for
substance abuse or dependence may not appropriately identify
older patients with dysfunctional
patterns of use, particularly in the context of comorbid medical
illnesses, physiological and
cognitive changes associated with age, and polypharmacy.
Increased detection of substance use problems in older adults
may be achieved through the
development of screening tools specifically intended for elderly
populations (Culberson, 2006b).
For example, the Short Michigan Alcohol Screening Test–
Geriatric Version is a 10-item screening
tool focused on negative consequences of alcohol use specific to
older adults. The Alcohol-
Related Problems Survey (APRS) is a 10-minute questionnaire
(completed alone or with family
assistance) that explores the relationship between alcohol
consumption and worsening health,
medication use, and declining functional status. Furthermore,

recognition by clinical providers
that even brief interventions can be effective in producing
positive change may increase clinician
interest in identifying older patients with substance use issues.
Limitations of this study include reliance on administrative
data, which are not based on
validated diagnostic assessments by trained personnel.
Treatment prevalence is the sole source
of data in this cross-sectional study. Older adults are generally
underrepresented within psy-
chiatric treatment populations (both inpatient and outpatient),
limiting our ability to draw con-
clusions about changes in the prevalence of dual diagnosis
related to age. Furthermore, the
study examined prevalence rates of diagnosed psychiatric and
substance use disorders, but
did not provide direct information on clinical severity, such as
level of symptomatology or
prognosis.
Data were not available on general disability status, including
social security disability. The
data in this study pertain to veterans served by the VA, who are
overwhelmingly male and
known to be older, poorer, and less likely to have health
insurance than those who do not use
VA services (Rosenheck, 2004). Older adults seeking treatment
in specialty mental health clinics
are also recognized to be nonrepresentative of the general
geriatric population, the majority of
whom receive treatment in primary health care settings. Thus,
the generalizability of this study’s
findings to non-VA populations, veterans or not, is unknown.
Nevertheless, within that group, use
of these administrative data provides information on a full

national sample treated in specialty
mental health programs across the country.
This study represents one of the few published thus far
evaluating the treated prevalence of
major psychiatric and substance use disorders among elderly
Americans, and it compares the
prevalence of dual diagnosis and service utilization within
specific psychiatric diagnoses across
age groups. The results of this study may be useful in program
planning and understanding
treatment needs. It generally suggests declining substance use
and dual diagnosis among the
elderly, but it may also raise concern about the possible
underdiagnosis of substance use disorders
among the elderly and the need for appropriate screening,
diagnosis, and treatment.
ACKNOWLEDGMENTS
Support was provided by the Department of Veterans Affairs
VISN 1 Mental Illness Research,
Education and Clinical Center.
DISCLOSURES
Dr. Kerfoot reports no financial relationships with commercial
interests. Dr. Petrakis reports no
financial relationships with commercial interests. Dr.
Rosenheck has no disclosures to report

regarding financial interests.
REFERENCES
Bartels, S. J., Blow, F. C., van Citters, A. D., & Brockmann, L.
M. (2006). Dual diagnosis among older adults: Co-occurring
substance abuse and psychiatric illness. Journal of Dual
Diagnosis, 2(3), 9–30.
Blixen, C. E., McDougall, G. J., & Suen, L. J. (1997). Dual
diagnosis in elders discharged from a psychiatric hospital.
International Journal of Geriatric Psychiatry, 12(3), 307–313.
Colliver, J. D., Compton, W. M., Gfroerer, J. C., & Condon, T.
(2006). Projecting drug use among aging baby boomers
in 2020. Annals of Epidemiology, 16(4), 257–265.
Culberson, J. W. (2006a). Alcohol use in the elderly: Beyond
the CAGE. Part 1 of 2: Prevalence and patterns of problem
drinking. Geriatrics, 61(10), 23–27.
Culberson, J. W. (2006b). Alcohol use in the elderly: Beyond
the CAGE. Part 2: Screening instruments and treatment
strategies. Geriatrics, 61(11), 20–26.
Drake, R. E., Essock, S. M., Shaner, A., Carey, K. B., Minkoff,
K., & Kola, L. (2001). Implementing dual diagnosis
services for clients with severe mental illness. Psychiatric
Services, 52(4), 469–476.
Federal Interagency Forum on Aging-Related Statistics. (2010).
Older Americans 2010: Key indicators of well-being.
Washington, DC: U.S. GPO. Retrieved from
http://www.agingstats.gov/agingstatsdotnet/main
site/default.aspx

Gfroerer, J., Penne, M., Pemberton, M., & Folsom, R. (2003).
Substance abuse treatment need among older adults in
2020: The impact of the aging baby-boom cohort. Drug and
Alcohol Dependence, 69(2), 127–135.
Gonzalez, G., & Rosenheck, R. A. (2002). Outcomes and
service use among homeless persons with serious mental illness
and substance abuse. Psychiatric Services, 53(4), 437–446.
Grant, B. F., Dawson, D. A., Stinson, F. S., Chou, S. P., Dufour,
M. C., & Pickering, R. P. (2004). The 12-month prevalence
and trends in DSM-IV alcohol abuse and dependence: United
States, 1991–1992 and 2001–2002. Drug and Alcohol
Dependence, 74(3), 223–234.
Holroyd, S., & Duryee, J. J. (1997). Substance use disorders in
a geriatric psychiatry outpatient clinic: Prevalence and
epidemiologic characteristics. Journal of Nervous and Mental
Disease, 185(10), 627–632.
Lyness, J. M., Caine, E. D., King, D. A., Cox, C., & Yoediono,
Z. (1999). Psychiatric disorders in older primary care
patients. Journal of General Internal Medicine, 14(4), 249–254.
Prigerson, H. G., Desai, R. A., & Rosenheck, R. A. (2001).
Older adult patients with both psychiatric and substance abuse
disorders: Prevalence and health service use. Psychiatric
Quarterly, 72(1), 1–18.
Regier, D. A., Boyd, J. H., Burke, J. D., Rae, D. S., Myers, J.
K., & Kramer, M. (1988). One-month prevalence of mental
disorders in the United States. Based on five Epidemiologic
Catchment Area sites. Archives of General Psychiatry,
45(11), 977–986.
Rigler, S. K. (2000). Alcoholism in the elderly. American

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