Authors: Kathleen Sciacca, M.A Christina M. Thompson, Ph.D.
Address correspondence to:
Kathleen Sciacca, M.A.
Sciacca Comprehensive Service Development for MIDAA
299 Riverside Drive
New York, N. Y. 10025
Journal of Mental Health Administration, Vol.23, No.3, pgs. 288-297, Summer 1996.
Numerous Bureaus of mental health, drug addiction, and alcoholism are designated to provide service to persons who have a discrete, singular disorder of mental illness, drug addiction or alcoholism. Mental health and substance abuse programs (nationally and internationally) have evolved with this singular, limited service capacity. Contrasting incompatible philosophies and treatment methods across the systems have resulted in minimal services for persons with dual diagnosis. The project the authors have outlined is an example of the development of a dual/multiple disorder program that integrates these diverse systems and provides comprehensive services within each of the programs within each delivery system. These programs are cost effective: they utilize existing facilities; train and cross-train existing staff; correct the issues of incompatible treatment interventions; and end the dilemma of gaps in services systems and limited referral resources. As a result, the availability and quality of care for persons with dual diagnosis is greatly improved.
In 1986, The New York State Commission on the Quality of Care for the Mentally Disabled found that 50% of the patients admitted for psychiatric care across New York State also had alcohol and substance abuse that required treatment.1 In 1987 the Alcohol Drug Abuse and Mental Health Administration (ADAMHA) reported that at least 50% of the 1.5 to 2 million Americans with severe mental illness abuse illicit drugs or alcohol as compared to 15% of the general population.2 Other studies in 1993 have shown that 90% of prisoners with a mental disorder have co-occurring substance disorders,3 and half of the homeless population with a mental illness also have substance disorders.4 Dually-diagnosed clients have been characterized as systems misfits with poor outcome, more relapses, more acting out behavior, and more likelihood of being homeless.5 Despite the documented high prevalence of co-existing mental illness and substance disorders, and the serious consequences, facilities that provide comprehensive services for dual/multiple disorders are limited as compared to services for singular disorders.
Mental health and substance abuse providers alike encounter difficulties in accessing comprehensive services for dually-diagnosed clients. The underlying reasons include the following:
The project the authors have initiated addresses each of the three underlying issues outlined above. In this article the authors will discuss a model of program development that has integrated the mental health and substance abuse systems in the Jackson-Hillsdale counties of Michigan. The authors will review program and staff development accomplished through an interagency process of cross-training and program implementation.7,8 This has resulted in comprehensive services at multiple sites within the mental health and substance abuse service delivery systems. This will be followed by an overview of a non-confrontational treatment model7 and accompanying philosophy developed specifically for persons who have dual disorders.
Assessment of Service Needs
Following a critical suicide attempt in April 1991, the Jackson-Hillsdale Community Mental Health Board Chief Executive Officer and the Executive Director of the South Central Michigan Substance Abuse Commission (a regional authority), reviewed statistics on substance abusing clients who also presented themselves in psychiatric crisis. The community mental health center provided 24-hour, 7-day a week emergency services which included face-to-face assessment of persons entering the emergency room at the general hospital. A major focus of this assessment was to determine the need for inpatient psychiatric care or other alternative treatment services. The Michigan Mental Health Code9 specifies that to be elegible for inpatient care individuals must be severely mentally ill and a danger to self/others/unable to care for their basic needs. The Michigan Public Health Code also states that emergency rooms must offer treatment for incapacitated persons taken into protective custody by a law enforcement officer.10 Hospitals under Federal EMTALA (Emergency Medical Treatment and Labor Act) standards were concerned about screening, admission and discharge issues for these persons. EMTALA defines the conditions for treatment as those medical conditions which manifest acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably result in placing the individual in serious jeopardy. Hospitals were prohibited from transferring or discharging patients with emergency conditions until stabilized.
Increasingly, the community mental health staff who performed the general hospital emergency room assessments were seeing intoxicated individuals with suicidal/homicidal ideation. Generally the individuals were held in the emergency room. Once blood alcohol levels were reduced, the community mental health staff would re-assess and find no severe mental illness or behaviors threatening to self or others that justified psychiatric inpatient admissions. From April, 1990 to April, 1991 forty-seven of fifty-five emergency room assessments revealed no necessity for psychiatric inpatient care based upon admission criteria in the Michigan Mental Health Code. Twelve of these individuals were recidivists to the emergency room, and fifteen were admitted to short term (2-3 day) psychiatric inpatient care for observation despite lack of an appropriate psychiatric diagnosis. These same fifteen clients were rejected for substance abuse residential treatment and their recidivism led them to become known as "revolving door" consumers. In the absence of acute symptoms of severe mental illness, and with a stabilized medical condition, clients were discharged from the emergency room. This situation posed a fear and major concern for both treatment systems and the general hospital.
The substance abuse agency, the community mental health agency and the general hospital were concerned about service delivery gaps and liability relative to abandonment issues. In addition, the parties recognized the need to connect individuals with ongoing treatment as soon as possible during the crisis periods since it was believed that effecting change is easier during such periods.
In 1992, a separate and independent report about the general hospital yielded the following data.11 From October 1991 to September 1992, seven psychiatrists ordered 87 alcohol and drug consults on a total of 79 patients (eight consults were repeated on the same patients during separate episodes). There were 82 consults on the inpatient mental health units, two consults were main hospital patients and three were outpatient mental health patients. This number comprises 53 males (60.9%) and 34 females (38.6%). The substance disorder diagnosis was confirmed through a series of screening tests and a face to face interview. Seventy six of the 79 patients assessed (or 96.2%) met the criteria for alcohol and/or drug dependence. This number constitutes only 8.3% of the total hospital admissions for that year. The report concluded that "dual diagnosis" case finding would be enhanced by alcohol and drug screening tests during the psychiatric evaluation period.11
Since the state laws separating the agencies would not be modified in a timely fashion, the directors decided jointly to focus on a continuum of care for both groups at risk in the two systems; and while crisis clients were an immediate problem, it was apparent that inpatient care and emergency room care were the most expensive services to provide, the least effective method for long term treatment, and the most utilized by these groups.
Planning for Integrated Services Across Systems
As a result of this initiative, in 1993, the South Central Substance Abuse Commission and the Jackson-Hillsdale Community Mental Health Board jointly funded a model program for persons with dual diagnosis of mental illness and substance disorder. The program was developed and implemented by Sciacca.7,8,12 To offer a comprehensive plan, the program incorporated and integrated elements of both systems throughout the continuum of services. The structure of state government could not be reorganized, therefore, the comprehensive service model identified specific areas of inter-system collaboration. This collaboration entailed a formulated and integrated philosophical perspective, redefined roles, and an integrated treatment approach. The goal was to provide integrated treatment versus sequential services. Since it was not financially possible to establish a separate treatment continuum for dually diagnosed clients, parallel treatment was proposed allowing for utilization of existing resources in both care systems.
The system was designed to meet the needs of clients in each phase of recovery, to include interventions that addressed various levels of severity and disability and various levels of motivation and readiness.7 This treatment model7,12 would be adopted by each of the participating program sites. The treatment model includes non-judgmental acceptance of symptoms of dual or multiple disorders upon admission to treatment, and a process of intervention designed to assist each client along a continuum of progress. Screening for the symptoms of dual disorders was implemented at each intake to assure that clients were identified. Continuity was to occur across programs as well as over time. The range of program elements included acute stabilization, engagement, education, comprehensive assessment, ongoing stabilization and rehabilitation, and relapse prevention. A service delivery system where each program site included integrated services for dual disorders was envisioned. The interventions would compliment each program's parameters including length of stay, primary service (i.e. acute stabilization), and model of service. A dual disorders "track" including engagement, individual and/or group interventions, and preparation for clients to participate in dual disorder services at the next service juncture, would be included at each program site. Clients would have the opportunity to utilize components of each system as needed. For example, a client with severe mental illness who is approaching acute crisis due to a substance disorder could receive treatment at a residential substance abuse program with attention to detoxification, rather than deteriorate into an acute psychiatric condition and be referred for inpatient psychiatric care. A person with a depressive disorder and alcoholism could attend a mental health clinic and participate in dual diagnosis group treatment.
This model of integrated treatment developed in 198412 had been implemented across various program sites, and across a number of states. The premise of acceptance of all symptoms, coupled with a component of dual disorder services on the site where the client receives his or her primary care, has proven highly effective. Clients who traditionally do not participate in substance abuse services due to their level of motivation, their failure to meet the readiness criterion, or their mental illness, are engaged at the level at which they are willing or able to participate. Non-threatening interventions including education and support have aided in moving persons along the continuum of readiness, motivation, understanding and acceptance of dual disorders, and ultimately as allies in their own recovery program. Within the substance abuse services, treatment interventions and education is provided for clients who have various degrees of mental health symptoms co-occurring with their addictive disorders. In addition, clients who have severe mental illness are accepted, and service programs are modified to provide interventions that the client can tolerate and complete successfully.
Initiation of Program Implementation Across Systems
A two-day introductory training seminar was developed and presented by Sciacca. The seminar was designed to solicit volunteers from programs across both systems and from the general hospital for the pilot project which included on-going training and supervision. The introductory seminar was open to all direct care providers, managers, and staff across both systems. Content of the seminar included cross-training in the underlying elements for the disorders of mental illness, drug addiction and alcoholism. Contents also included issues related to divided mental health and substance abuse systems from a bureaucratic perspective, a clinical perspective, and a philosophical perspective. A "non-confrontational" treatment approach7,12 for the dually diagnosed was outlined. This included interventions from "denial" to "recovery," and denoted the various starting points and motivational levels for persons with mental illness and substance disorders.7 Program tools for both mental health and substance abuse services from the MIDAA Service Manual 13 were outlined. The respective directors of each care system openly expressed their support for "interagency" 7,8 cross-training and program development across the systems. This "administrative support" is noted by the dual diagnosis specialist to be an essential and often crucial element of MIDAA program development and systems change. It is important that support be expressed openly, (often in writing) and continually throughout the process of implementation and application.
The administrators and the consultant agreed to include each program site providing services to adult and adolescent clients within the community mental health system, each program site providing services to adult clients within the substance abuse system, and the psychiatric unit at the general hospital. Site visits and management meetings followed the selection of the program sites. These meetings included the specifics of program implementation at each site including staff development.
Following the introductory seminar there were more volunteers than training slots. The on-going training commenced with a group of eighteen participants, representing twelve program sites. The mental health sites included: two outpatient clinics; a day treatment program; a psychosocial rehabilitation clubhouse, modeled after Fountain House14; outpatient adolescent services; two crisis residences; two assertive community treatment (ACT) teams15 ; and an inpatient acute psychiatric care unit. Substance abuse sites included: residential inpatient substance abuse treatment; substance abuse partial day treatment; substance abuse intensive day treatment; and two outpatient substance abuse clinics.
Staff who participated were to become the resource person (versus expert) to their program team. As a result of this project, each site has developed a dual diagnosis program.
Content of Cross-Training and Program Implementation
Working Definitions of MIDAA Profiles
The State of Michigan Department of Mental Health has adopted Sciacca's criterion7 as working definitions of Dual/Multiple disorder profiles. These working definitions have also been adopted by other states.
For purposes of staff development, these definitions lend clarity to the differing profiles of MIDAA populations found across the systems. They are referred to when considering special service needs across the two systems and when developing specific treatment plans.
Participants were supervised to provide group and individual treatment interventions that meet the special needs of their clients and were in keeping with the goals and objectives of their program. Their training included the utilization of each program form. They participated in formulating the protocol set in place at their respective site.
Each agency implemented a "screening" form that was applicable either to mental health or substance abuse clients. Screening would lead to the appropriate follow up for treatment. The modified version of the CAGE18 questionnaire, the dual diagnosis CAGE13 (D.D. CAGE) was used at all intakes for mental health clients, and the MISF (mental illness screening form)13 was used at all intakes for substance abuse clients. Figure 1 outlines the Sciacca treatment model7 and sequence of related MIDAA program forms.
In addition to providing treatment services in their respective program sites, some participants from both mental health and substance abuse co-facilitated treatment groups at alternative program sites. This was reported to be a valuable learning experience. It also provided opportunities for professional integration into the alternative system.
Each training meeting included an educational topic. Topics were selected and reviewed by the participants. Participants read literature, prepared and presented MIDAA case reviews, and administered and presented comprehensive assessments. Participants continually updated the status of program implementation at their program site.
Program managers were asked to provide staff with four hours per week to provide MIDAA services and to participate in training. The weekly time allotted was averaged from monthly estimates.
In effect, the cross-training process provides each liaison/staffer with education, training, a built in internship(s), supervision, and an understanding of program development. Simultaneously the liaison/staffer provides dual diagnosis treatment services for the clients, resources for the program site, implements a program forms for the agency, and provides an essential link in the continuity of care network across (the community of) services.
Program Philosophy and Description
The treatment groups were designed to include from two to eight members at any time, and to incorporate a non-confrontational, non-sequential approach. Treatment groups process all illnesses and related experiences (both mental illness, substance abuse and interaction effects). Clients were exposed to educational materials as they gradually increased their recognition of symptoms. As trust developed, they progressed along the readiness criteria to ultimately participate as allies in their own treatment7 and recovery. Clients were encouraged to remain on necessary medications, and for the most part continue to attend the program(s) where they were most comfortable. Clients who refused to meet with the liaison/staffer for the pre-group interview continued to engage with the primary provider who proceeded to educate the client about dual disorders in a non-threatening, non-confrontational manner, using statements of concern, until there was movement along the continuum of engagement.
Treatment groups in program settings incorporate the following characteristics. Abstinence is a goal not a requirement. Clients with substance abuse (not physically addicted) and substance dependence (with physical addiction) receive treatment together. Clients progress from non-confrontational educational approaches where they have high denial and/or low motivation to more active involvement in treatment as they progress along the continuum of acknowledgment of substance use; insight into substance abuse or dependence; motivation to abstain; abstinence; and relapse prevention.7 Throughout each of these phases clients are taught and encouraged to be supportive of one another as they help each other acquire new skills and insights and attain or maintain sobriety.
Specific education about both mental illness and substance abuse disorders is essential. The interaction effects of dual disorders, and the interactions between illicit substances and prescribed medications are unique topics and areas of exploration. Participants are taught to dispel moral judgmental concepts about addictive disorders and stigmas about mental illness. Instead, they learn the true underlying factors of these illnesses and recovery from them. This assists clients to move from demoralization, shame and guilt to hope for rehabilitation, recovery and stability. Group members are encouraged to provide peer support and to share experiences and knowledge in a non-threatening, non-judgmental environment. Candidness is valued as the only real possibility for genuine learning and understanding to occur. There is no time limit (except for those imposed by program parameters) for successfully engaging the client in the group process as well as assisting the client to progress along the continuum from denial to recovery (see figure 1). Once the client is an ally in the treatment process (phase 3), various treatment interventions may be recommended. Other adjunct supports may be included at any point along the continuum of recovery including twelve step programs, and other supportive environments. Clients are assisted to adjust to adjunct programs during their participation in MIDAA groups. Each disorder is viewed as a potentially relapsing illness. Interrupted treatment or relapse is viewed as a learning opportunity, and an aspect of the illness, it is not viewed as failure. Involvement of family members is encouraged.19
This model was presented with the understanding that clients may move from one program to another or participate in more than one program at any given time. The continuum was therefore flexible.
Cross-Training and Program Development Outcome
In the summer of 1994, at the close of the ten-month training segment the following outcome was demonstrated.
Seventeen liaisons/staffers were in participation (Twelve participants from mental health, and five participants from substance abuse programs).
Questionnaires were completed by eleven mental health participants and four substance abuse participants. It was documented that none of the eleven mental health participants have had prior training, or experience in the treatment of substance disorders or dually diagnosed clients. As a result of this MIDAA training, all mental health trainees are providing treatment services for the dually diagnosed. Seven participants each lead one group in the mental health services; two participants lead one group in mental health and co-lead one group in substance abuse services; one participant leads two groups in the mental health services; one participant co-leads one group in the substance abuse services. Of five substance abuse participants two with prior mental health experience, three with prior dual diagnosis training (not extensive), five have never led a dual diagnosis treatment group prior to this MIDAA training, all five participants lead at least two dual diagnosis groups, one in substance abuse programs, one in mental health programs, one leads two groups in mental health and one in substance abuse.
A multiple choice exam was administered to 16 participants. The exam included both mental health and substance abuse diagnostic questions, and dual diagnosis treatment and assessment questions. Of a total of 11 questions the group mean score was nine (i.e. nine correct responses of 11).
In self reported learning on the questionnaire participants rated the following categories as areas of acquired knowledge during this MIDAA training:
Each of the 11 mental health respondents gave an affirmative specific example of a "program benefit" they recognized as a result of including MIDAA treatment groups. A majority of the responses included either or both of these areas as beneficial to the program site: 1) comprehensive treatment for dual disorders and 2) cross-disciplinary training. Each of the four substance abuse respondents gave an affirmative response of: 1) comprehensive treatment benefit or 2) a cross-training benefit.
In response to the question, "How have MIDAA groups benefitted the clients in your program?" Each of the 11 mental health liaison/staffers responded positively with the following client benefits repeated across responses: learning, insight, open expression, decreased shame, reduced denial, reduced substance abuse, abstinence, on-site comprehensive treatment, and increased resources and socialization. Three of four positive substance abuse responses included: client inclusion in treatment; comprehensive treatment; open expression; and reduced shame and stigma.
Summary Across Mental Health and Substance Abuse
As a result of the cross-training and program implementation, every participant conducts one or more treatment groups. Sixteen separate treatment groups for dually diagnosed clients are being conducted across both mental health and substance abuse services. Five substance abuse participants co-lead a dual diagnosis group(s) in a mental health setting, four mental health participants co-lead a dual diagnosis group in a substance abuse setting. None of the participants\respondents have led a dual diagnosis treatment group prior to this training.
In addition to education and skills, a number of the participants indicated throughout the training that they had gained respect for the clinical work performed by their colleagues in the alternative system.
At the close of the ten month training seventy-nine clients were receiving dual diagnosis treatment across the program sites. Many of the mental health clients had never participated in substance abuse treatment prior to this dual diagnosis treatment, and others never in a sustained way. Clients who were regularly found in the substance abuse system participated in groups that addressed both substance abuse and mental health. An increase in participation of MICAA clients was found in the substance abuse system. Monthly group statistics13 show that numerous clients have sustained their participation in dual diagnosis treatment in an on-going way within programs and across programs. Empirical case reviews and preliminary progress data show progress has been achieved in each of the areas on the progress reviews13 by various clients. Quality of care was remarkably enhanced within programs and through the availability of services in the alternative systems. The monthly training meetings provided an understanding of the services provided in each program. This assisted in the development of service plans that were more closely attuned to a client's treatment needs at specific points in his or her recovery. As a result, the potential for successful completion of a particular program was greatly improved. The second phase of this project will include the compilation of client progress outcome data.
Trainees received certificates of completion and attendance at a luncheon that included program managers and the principle initiators of this project, the Mental Health Board Chief Executive Officer and the Executive Director of the South Central Michigan Substance Abuse Commission. Upon commending each participant for their contribution to the success of this project, both administrators reminded their constituents of the disparate and estranged relationship between the two systems at the time this project began. The dual diagnosis specialist grasped the true accomplishment of cooperative and integrated systems simultaneous with the accomplishment of the provision of integrated treatment services.
Implications for Mental Health Administrators
The results of this project clearly demonstrates the ability for both mental health and substance abuse services systems to combine their resources for the benefit of dually diagnosed clients. Agencies that are alienated from one another can bridge these gaps through cooperation, education and training. The commitment of the administrators from both systems in the Michigan project demonstrate this. The same commitment is possible by other administrators who wish to correct the condition of "systems misfits" to one of comprehensive services for dual disorders within and/or across systems and services.
Comprehensive, integrated treatment services can be provided within a broad range of program models, thereby providing clients the opportunity to receive services in the setting where they are most comfortable. Existing programs and existing staff comprise the resources necessary to change systems and services. Clients do not have their treatment interrupted. Rather, their service program is enhanced by the inclusion of MIDAA treatment. Renumeration for services remains within the categories already specified, i.e. assessment, group treatment, counseling, etc.. The client attends the service system most appropriate, and that system indicates the "principle" diagnosis17 to justify attendance. This model of "integrated" treatment does not require change at the bureaucratic level.
Agency benefits include available dual diagnosis services, thus, increased efficiency and increased revenue through client engagement versus client detachment.
Staff who are motivated to learn and to provide new program initiatives are highly effective as providers of treatment for dual disorders. Didactic and experiential training can provide the understanding necessary for employing new models of intervention. Differences in philosophy and methodology across systems are narrowed as the service needs of the dually diagnosed client are better understood. An accepting stance of "inclusion" can replace criterion for exclusion.
Mental health providers who once believed they could be of no value to a person with a substance disorder now diligently extend every resource to engage the dually diagnosed client into treatment. Substance abuse providers who once avoided clients with a severe mental illness now provide services for these clients in both systems. In effect, the Jackson-Hillsdale project has demonstrated that dually diagnosed clients who were "no one's" clients in the initial revue of the issues, have now become "everyone's" clients as a result of this project. This process is replicable where there is administrative support, motivated direct care providers, the employment of a realistic "inclusive" treatment model and service delivery, and the provision of education and training.
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