Fred Osher, M.D. is a man of action and compassion in the field of co-occurring disorders. He entered the field when there was little understanding of the issues presented by people who experience both severe mental illness and substance use problems. Fred has dedicated his career to developing effective treatments for people with co-occurring disorders. His path has been marked by important mentors, courageous people, and the development of new treatment approaches. Currently, Fred is Director of Health Systems and Service Policy for the Justice Center of the Council of State Governments.
In the late 1970s, Fred was the Medical Director for a Salvation Army Detoxification Clinic that provided substance use services and psychoeducational treatment. Fred recognized that there were some people coming through their doors who did not succeed. “They were not focused in discussions and groups. They were marginalized by other patients in the setting. I had no idea why this was happening. I thought it seemed odd. But the explanation of a group of people being odd seemed inadequate,” says Fred.
At this time, in the 1970s, there was confusion as to whether people with substance use disorders would be treated by neurology or psychiatry. Eventually psychiatry would become the dominant approach for understanding and treating co-occurring disorders. Fred decided to learn more about co-occurring disorders by doing his psychiatric residency at the Dartmouth Medical School. It was in this setting that he established important perspectives on the interplay between the two conditions.
During his residency, Fred was supervised by Dr. George Valliant, a leading thinker on substance use disorders. After his residency he worked at West Central Services community mental health centers where Dr. Robert Drake was his supervisor. Later, while working at the National Institute of Mental Health, he worked with Dr. Irene Levine. This experience gave him a strong understanding of the range of community supports required to support recovery, like affordable housing and entitlements. With the support of these three mentors, Fred developed an understanding of the need for phases of treatment for people who experience co-occurring disorders. “We identified co-occurrence as one of the primary features that prevented success in the existing mental health treatment programs. People with mental illness diagnoses were not doing well in substance use programs. And people with substance use problems were not doing well in mental health programs.”
Fred and colleagues developed a response outlining phases of treatment for people with co-occurring disorders. This was grounded in an understanding of the change process. The phases of treatment model is a platform from which a great deal of work has been accomplished. Robert Drake’s subsequent research on this model resulted in a shift from purely academic interest to applied science. “We affirmed the concept that change takes place over a period of time, and that recovery from addiction is interdependent on recovery from mental illness,” says Fred. This led to a more global concept of the need for integrated treatment. This concept takes into consideration the convergence of personal motivation, clinical interventions, and motivational states.
A 2002 report to Congress outlined broad issues related to co-occurring disorders and identified effective responses, creating a common language. The report recommended the development of grant programs and centers of excellence. As a result, SAMHSA supported a range of grants and contracts to promote new knowledge generation.
Now, evidence-based research supports the effectiveness of integrated treatment systems for people with co-occurring disorders. Yet, there continue to be systemic barriers to care. “The separation of mental health and substance use services,” explains Fred, “is fueled by the separation of funding streams.” This trickles down to the programmatic and provider levels. For example, there are licensing regulations that separate the mental health and substance use treatment workforces. “At the training level we have begun to make inroads into residency programs and medical schools. But even this is not as advanced or as common as we would like,” says Fred.
Despite systemic barriers, Fred is hopeful about the future. “What sustains me is recognizing the gap between the services people have access to and what we know about what works. It is important to me to be part of a community that works to close this gap. With the appropriate supports, care, and respect, I know that people with co-occurring disorders can succeed in achieving their goals,” says Fred.
For the past 12 years, Fred facilitated an integrated treatment group called Second Opinion at Health Care for the Homeless in Baltimore, Maryland. He explains that he has been humbled by his inability to predict success. He shares that there is a cohort of individuals who had a profound impact on his perspectives. He is very optimistic about people’s capacity to change.
“Second Opinion was as important to my growth and understanding as it was to the members of the group. They showed great courage in the face of hardship. They laughed under circumstances that I could never have tolerated. They are the heroes in my life. What I learned from them about how to adapt and use survival skills offered me a set of lessons I could never have achieved on my own. I have seen so many people who have turned their lives around,” says Fred.
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