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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

*Name changed to protect patient’s privacy

About this Initiative

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

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