1. Kub, Joan PhD, MA, PHCNS-BC, FAAN
  2. Editor:

Article Content

I had the privilege of interviewing Connie Mele, Assistant Health Director for Mecklenburg County, North Carolina. Her experiences are so varied and rich. She recently served as the President of the North Carolina Foundation Board for Alcohol and Drug Studies. She served on the North Carolina Substance Abuse Processionals Practice Board and was instrumental in the implementation of deemed status for nurses with the CARN-AP. She served as the Chair for the Addiction Nursing Certification Board and began the initial assessment to determine what was needed to accredit the examinations. She teaches at the UNCC School of Health Professions and Wingate University on "How to Deal effectively with the Chemically Dependent Patient" and "The Impaired Nurse." Connie served as a reviewer and contributor to the revised Scope and Standards of Addictions Nursing Practice as well as chaired the committee to revise the CARN Study Guide.


Q: I am so excited to talk about your career and your accomplishments. You have worked for over 35 years with a focus on behavioral health, specifically addictions. Can you describe your career path since this has been and continues to be your focus?

A: I started my career as a nurse in a community methadone clinic. I really didn't learn about addictions in my ADN program. I learned about psychiatric nursing but didn't know that addictions was actually a place for nurses to work. So I saw this job, it sounded sort of "psychish," and I applied. This is how I literally fell into this field of addictions. What a great opportunity it was to learn about the hard-core addict. They had so much to teach me. I knew I wanted to work in addictions nursing for the rest of my career.


I worked then in an outpatient clinic, where they had never had a full-time nurse. That was where I learned the importance of belonging to my specialty nursing organization. There really wasn't anyone to ask about whether I was doing things correctly. There were no books or articles. My first specialty meeting was the National Nurse Society on Alcoholism in 1983-1984 in Texas. I was ecstatic to be with "my people," so to speak, and to find out what the best practices were for nurses in all types of addiction settings.


I was working on my BSN degree at this time, and when I graduated, I went to an inpatient treatment center as the Director of Nursing. This was my first experience with inpatient nursing and addictions. It was a great experience because we had detox, residential treatment, where people were there for 28-42 days as well as family and outpatient treatment. We got to see people get well. I left there and began teaching psychiatric/mental health nursing in a diploma school of nursing. The students were so afraid of the patients, scared to death that something bad would happen to them. I knew I had a made a difference when I was able to help students see their patients with psychiatric diagnoses as individuals with a brain disease. As their level of comfort grew, they were able to provide effective care, provide empathy, and give hope to their patients until the patients could have hope for themselves. Of course, it provided me an opportunity to illustrate how often there is a co-occurring substance use disorder with many psychiatric diagnoses. It was the perfect job as I entered graduate school.


My next professional opportunity was to open up a treatment program with the national treatment provider, Parkside, at a local hospital. It was the only treatment program in the community. This was my first opportunity to start a program from scratch, hire the staff, and open the doors. It was a 20-bed facility. It was a perfect opportunity to put into place all those ideas you have when you say, "If I ever run a program this is what I'm going to do"-and you realize some of your ideas are good, and others are not so. We utilized best practices and got the program JCAHO accredited. It was a great professional opportunity to develop the program that was so desperately needed in our community.


I then went back to teaching psychiatric nursing while I was completing my Master's degree. I really tried to help students realize that someone with an addiction or psychiatric illness does not wake up one day and make a conscious decision to have a substance use disorder or psychiatric illness. I also wanted them to understand that, in addition to medication, there are behavioral components to treatment and recovery, not that dissimilar from heart disease or diabetes. Yet, those diseases do not carry the same stigma that psychiatric and substance use disorders do. In my current position, this same message holds true. Whether I am teaching police and detention officers in our Crisis Intervention Training or presenting to County Commissioners, they need to understand that relapse is part of the disease and people may need more than one treatment episode not unlike someone who has had a MI. We don't call people weak or morally flawed who have a second heart attack or have difficulty getting their diabetes or blood pressure under control. Bill Clinton said, "Mental illness is nothing to be ashamed of, but the stigma and bias shame us all."


I left teaching to start an outpatient behavioral health program, which included mental health and substance abuse counseling as well as vocational counseling, which was an important aspect. I really do believe that everybody wants to be somebody, and regardless of their disability, they want to contribute to their community. I then returned to be a Director of Nursing, not just in a substance abuse facility but also a psychiatric facility, which included adolescents with conduct disorders. It was an opportunity to make a difference in a young person's life. I left there to come to Mecklenberg County to run their substance abuse (76-bed) facility. Within 6 months, I was asked to evaluate services and gaps in the community to ensure that people were getting the services that they needed. This eventually led to my becoming director of behavioral health services for the county for 11 years. During this time, our State and County began undergoing mental health reform. Many of the services we were providing were being contracted out to private providers, although the county decided to keep the more critically ill/fragile clients to provide a safety net for them. I directed services for those with mental health, substance abuse, and intellectual/developmental disabilities until 2015.


Q: Can you tell us about a few of your special programs focused on these special populations?

A: At that time, while we were focusing on case management, we also focused on children (0-3) with developmental disabilities and began to look at the mental health needs of these children as well. We also began to expand the child development community policing program. This is a program that we have had for 20 years in partnership with Yale University. We look at children exposed to trauma and violence. The way the program works is that, when the police identify a child exposed to violence, they call our mental health clinician to come and start working with the children. We have learned that children exposed to violence and trauma early in life can experience brain changes, making them more susceptible to mental health, substance use disorders, and violence later in life.


While working on this, I had an "ah hah" moment realizing that we should look at inmates with mental health problems within our 2,600-bed jail. Depending on the day, the prevalence of individuals with mental health diagnoses varies between 25% and 50%, but generally, there is an average of 47%. At this time, jail diversion programs needed the buy-in of many stakeholders. I asked a diverse group of criminal justice officials (sheriff, police chief, district attorney, and public defender) to support the formation of a task force; all of them agreed, and the work took 1.5 years. We developed an algorithm that identified all appropriate jail diversion steps from what police can do when they encounter a person with mental illness to the end goal of permanent housing. We developed CIT-Crisis Intervention Team Training for police officers on mental health, substance abuse, and developmental disabilities. We also knew that not everyone could be diverted so we added detention officers. Our first class was in August 2008, and since then, over 1,000 officers have been trained in this 40-hour curriculum. This training includes a consumer panel that is especially moving as well as sending them to MH/SA treatment programs to see clients when they are not in crisis. Usually, the police only see these individuals when they are at their worst. It is an eye-opening experience. The diversion program also focuses on housing. We can have the best treatment programs, but if individuals do not have a safe place to live or food to eat, they won't be able to maintain their recovery or stability. We need to look at the social determinants of health as they are just as important as the treatment services.


So this jail diversion continuum was developed, and I thought I would have to get a grant to be able to fund any aspect of it. But at this time, we had a severe overcrowding problem at the jail (2,600-inmate capacity), and the County was entertaining the idea of building another jail. I stressed that, if we could get the mentally ill out of jail, the census could decrease dramatically. We submitted information on the jail diversion model to the county commissioners. We were given a half year of funding because it was much cheaper than building a new jail. We were then given full funding later, and now, today, the jail averages 1,450 inmates. Certainly, not all of the decline can be attributed to jail diversion of those with behavioral health issues, but it did contribute significantly to the decrease. This is an example of using the nursing process-identifying the population and starting by getting the right stakeholders to the table. It is doing an assessment, planning, and implementation and evaluation, and if something didn't work, determining what was needed. Nursing has served me well. We look at things differently. We are always triaging, evaluating, and thinking ahead. In behavioral health, we are the only member of the team (besides the MD/NP) who look at the whole person-the biopsychosocial aspects for each person we serve.


Q: You then assumed roles within the health department. Can you tell us about that?

A: About 7 years after this, there was some discussion with the new county manager about the need for more integrated services. I moved with some of my divisions (200 employees) to the health department, which had 625 employees. We have looked at how to be innovative and consequently just applied for a CMS grant with Community Care Partners of Greater Mecklenburg to develop an Accountable Health Community. We are very concerned about the multiple social determinants that can make a difference in a person's recovery-food, transportation, housing, utilities, and interpersonal violence. These are just as important as the treatment aspect. We hope to get this grant to address these issues, but if not, my hope is to talk to community stakeholders, funders, and county officials to determine an alternative way to fund this project.


Q: You have been successful at receiving several grants. Can you discuss these?

A: The first one was a 2001 SAMHSA grant focused on the development of an assertive community treatment team. At the time, these grants were for people with mental health disorders and not substance use disorders. I wrote this for people who were high utilizers-chronically ill patients with a primary substance abuse disorder who also had a co-occurring mental health disorder. The team consists of the psychiatrist/addictionologist, nurse, and counselor. We meet the person where he or she is-keeping them stabilized in the community so they do not have to go into the hospital or jail. This ACTT still exists today.


The next grant came out of an HIV/AIDS committee I served on. One of the members was from Duke University, and she liked what she was hearing about BH Programs we had in the county. She asked me if we could partner to develop an SUD treatment program for patients with HIV/AIDS, through HRSA grant funding. The idea is that anyone with HIV/AIDS will go into treatment but not disclose their HIV status, thus not working on the many issues that come with being HIV positive or having AIDS. This grant provided specific treatment and support for these patients. This program continues as well.


The next grant was with the state of North Carolina and was a jail diversion grant for veterans who suffered from PTSD/trauma. We offered treatment, case management, and a veteran's specialist to help with VA benefits including housing support. The last grant program was an HRSA grant that the state received to work with people with traumatic brain injury (TBI) and substance use disorders. The goal was to train substance use treatment facility staff how to assess for a TBI and then how to modify groups for those with TBI so they could effectively attend treatment. I assisted in the development of a training video where I was the counselor in the group and with finding a provider in Charlotte who was willing to integrate someone into their outpatient program who has a TBI. We also worked with developing our own TBI AA meeting. In Charlotte, we also have a 12-step club, and they have allowed us to have outbid meeting there.


Q: Can you talk about your role as a health officer?

A: My most recent role is Assistant Health Director of Mecklenburg County. I am responsible for the health clinics, WIC, policy and prevention, and children's developmental and trauma and justice services. My goal is to meet the needs of the community through the development of a number of programs and initiatives. I want to integrate behavioral health into the physical health programs we offer. As a RWJ Public Health Nurse Leader, one of the areas we are focused on is the role of the nurse in creating and maintaining a culture of health. My mantra about that is, "You cannot have physical health if you do not have mental health." My project will focus on postpartum depression in women enrolled in WIC as well as women who bring their children to the immunization clinic. We must take advantage of any potential encounters with all patients. The second part of my project is to help nurses across the state see how they too can be a catalyst of change wherever they work, to create a culture of health.


Q: You have really played so many roles including that of a nurse educator. Can you talk about your efforts in nursing education?

A: Since the early '80s, I started to go to nursing schools to offer to talk about the needs of patients with addiction problems. What I was hearing from patients was how badly they were being treated in healthcare settings. Then I heard how in the hospital, the staff would say, "John is back." Give him a couple of days, he will be in DTs. If nurses and physicians knew better, DTs didn't have to happen. As I heard these comments, I thought it would be helpful to hear a different side, so while I lectured on neurobiology and others, I also wanted to educate about the disease of addiction to humanize the illness. The person you are taking care of is not any different than caring for someone with a chronic illness with behavioral component. I continue to do it to this day; unfortunately, as nursing schools integrated mental health coursework into other specialties, there was less time for lectures on this topic. As that was happening, I then took the tactic of offering to talk about impaired nurses in the leadership courses, which allows me to speak about many of the aspects of the disease of addiction that they can translate to their patients.


Q: Can you talk more about your efforts regarding impaired nurses?

A: In the early '80s, I was asked by the North Carolina Nurses Association to serve on a task force about dysfunctional families-which at that time typically translated into adult children of parents with substance abuse disorders. That grew into developing a quasi-peer assistance program. We developed a core of volunteers across the state to help address nurses with impaired practice; we offered education and referral. A resource booklet was developed, and we offered trainings to any facility that employed nurses. We gave phone numbers that could be called 24/7, and we gave a list of referrals. This program was not tied to the Board of Nursing. We had no authority over the person. The program lasted for about 10 years, and then, we began losing some of our volunteers and could not find anymore. NCNA said, if we could not offer the service for everyone across the state, we needed to stop doing it.


So in Charlotte, our CADUCEUS support group is for physicians, pharmacists, dentists, physician assistants, and veterinarians, but they do not allow nurses to attend. CADUCEUS groups across the country usually allow nurses to join. So in 1996, I decided to start a support group for nurses to help nurses realize they were not alone and assist them in working with the Board of Nursing. I really think that every nurse confronted with addiction believes he or she is the only nurse who has ever done this. There is an intense amount of shame and guilt a nurse experiences. I believe that every addict and alcoholic experiences shame and guilt; every female addict or alcoholic has exponentially more, and every nurse has even more. Just those feelings alone, the shame and guilt, they need someone to talk to that is a nurse. It is a weekly group; I do not charge for the group. I see it as a way to give back to my profession. I feel fortunate that some of the nurses who started with me in the beginning still come back, which is helpful to newer nurses. This gives them hope-that they too can recover and return to nursing. The dental board has also contacted me and asked if dental hygienists could come to this group. I asked the group, and they agreed so we now have dental hygienists attending as well.


In addition to the recovery group, I started a weekly aftercare group since the Board of Nursing decided that every nurse in recovery must do 52 weeks of aftercare. Aftercare programs are typically 9-12 weeks long. I decided to develop an aftercare program for nurses-with a planned curriculum focused on topics such as shame, guilt, gratitude, and meditation. It is a great opportunity to see someone grow and thrive who has been through a year of recovery return to nursing. In NC, nurses do lose their license immediately; no other health profession loses their license immediately. Eventually, they get a restricted license returned to them. It then is a challenge for them to find work. I worked hard at finding employers who are willing to hire nurses who have a restricted license. It really depends on the facility that they interview with and if they believe in giving people second chances or not. The statistic is that nurses with impaired practice typically graduated in the top one third of their class and had responsible positions. Finding employers who are willing to understand the situation and give a person a second chance is not easy. Employers have a lot of misperceptions about what a nurse can or cannot do. Hopefully, there will be more employers being willing to give recovering nurses a chance. Most nurses that this happens to often think they should just leave the profession. I try to help them realize that they should not quit but get their license back free and clear and then decide if they still want to quit. I would say that, in the 20+ years, only five nurses have gotten out of the profession, and they did not get their license back-they quit before they finished the program.


Q: In all of these leadership roles you have had, do you have any words of wisdom to share with other nurses about creating change?

A: I think the example that comes to mind is the deemed status for nurses that I helped implement in North Carolina, with the Counselor Certification Board. After several certifications and advanced education, I was faced with the question of whether I wanted to get certified as a substance abuse counselor, to have the credential that would give me the legitimacy needed, since at the legislative level, substance abuse counselors were perceived as those with special knowledge and skills. So I went to the certification board and told them I had my CARN-AP, and it covered many of the same domains as the counselor certification. Eventually, we were able to develop deemed status, so if you were a nurse with a CARN-AP, you could apply for deemed status. As long as the nurse maintains their addiction nursing credential, they can receive the LCAS (Licensed Clinical Addiction Specialist) credential.


After I had been in the field for 5 years or so, I was dismayed to realize that, in many facilities, nurses were seen as important only during the detoxification phase. The opinion was that they certainly were not qualified to counsel patients. Yet, I found it interesting, every day at 5, all the counselors went home, and the nurses were left to take care of all of the patients' needs, and when do you suppose most patients had their crises? I wanted nurses to be able to practice to the full extent of their license and training. I knew I had to demonstrate to leadership the capabilities of nurses. I was very proud when I was able to do this and show that nurses on assessment, counseling, and utilization management teams were the only team member who could also look at the "bio" part of the biopsychosocial needs of the patients. They came to be viewed as an asset to the team.


So for me, the message is that one should not think that things can't be done but instead to ask how it might be accomplished. Henry Ford said, "If you think you can or you can't, you probably are right." If you come up upon something and believe there has to be a better way of doing it, get a group of people together and begin to test your hypothesis.


Q: I have one last final question. As you look into the future, what can we do in nursing to shift how we in nursing view substance misuse-not as a behavioral issue but a true public health issue?

A: I think we need to begin to clearly understand that our patients, wherever we encounter them, bring their whole selves to us including all the experiences they have had in their life. We can treat whatever the illness is and give best care, but if we don't realize that when they leave us, if they don't have a safe place to live, food to eat, and hopefully a job, their chances of staying clean and sober and in recovery is very unlikely. How can we expect people who don't have their basic life's needs met to be able to maintain recovery? We really need to look at the social determinants of health and realize that we need to address all of these needs. Otherwise, people will just cycle through services, and the last thing they need is another failure in their life. It sometimes feels insurmountable to make all of these changes. So that is where you learn to start with one part, then another, and another. As the saying goes, "If we always do what we always did, then we will always get what we always got." Or another favorite is the definition of insanity, doing the same thing over and over again, expecting different results.


The other essential element is beginning to recognize and treat the trauma many of our young children are experiencing, like the child development policing program described above. But it can be any type of trauma-informed care. This is important so they don't grow up to have the myriad of problems that untreated trauma can cause. Social mobility and poverty are also important aspects as well as the ability to get a job (that pays a living wage) with a past arrest history. If we could accomplish all of these, it would make such a difference for the people we serve. It all starts with one idea or thought[horizontal ellipsis]one day at a time.