By: Kathleen Sciacca, M.A. Executive Director, Sciacca Comprehensive Service Development for Mental Illness, Drug Addiction and Alcoholism, MIDAA, Tel: 212-866-5935, e-mail: ksciacca@pobox.com URL: http://pobox.com/~dualdiagnosis

Invited response to section on co-occurring addictive and mental disorders. Published letter to the editor. American Journal of Orthopsychiatry (66) 3, July,1996.

To The Editor,
The opening article of the Journal's special section (Osher & Drake,1996) which traces the history of separating mental health and addictive services, is an important contribution to the literature on dual disorders. Since we are now in the early stages of the evolution of dual diagnosis services, however, I believe it is important to provide a more complete and detailed account of the previous initiatives in this field.

In response to the article by Drake, Mueser, Clark and Wallach (1996) which states "Ten years ago the only treatment options available for people with co-occurring substance abuse and severe mental illness were parallel treatments in separate programs" (p.49), the record requires correction. Dual diagnosis treatment interventions and "integrated" programs that truly adapted to the needs of severely mentally ill chemical abusers (MICA) began in 1984 (Gigliotti,1986, Sciacca 1987a,1987b) in a New York State outpatient psychiatric facility. In 1985 these integrated treatment programs were implemented across multiple program sites (Sciacca,1987b). Concurrently, treatment and program elements were taught through training seminars in New York as well as nationally. Early articles by Gigliotti, 1986 and Sciacca, 1987a, 1987b, outlined these processes and documented their starting dates. In September, 1986, the New York State (NYS) Commission on Quality of Care (CQC) released the findings of eighteen months of research. Its report (Sundram, Platt, Cashen, 1986) described the detachment and downward spiral of dually diagnosed consumers who were bounced among different systems with " no definitive locus of responsibility." As a result, Governor Cuomo designated the NYS Office of Mental Health as the lead agency responsible for coordinating collective efforts for this population. CQC proceeded to visit the dual diagnosis programs developed in 1984, and declared the treatment interventions, the training, and integrated programs to be positive solutions to the dilemmas (Gigliotti, 1986). TIME magazine learned of the CQC report, and CQC suggested that TIME magazine investigate these programs. A reporter sat in on treatment groups, interviewed consumers and the director, and attended related training seminars. The story (Gorman, 1987) was held due to an international crisis, and later published with a survey of national dual diagnosis statistics (Ridgely, Osher, & Talbott, 1987). Hence, the "doubly troubled" were brought to the attention of the general public.

The Governor's task force put forward a vision for statewide program development. The "MICA Training Site for Program and Staff Development, New York Statewide" was created to attain that vision (Sciacca 1987b, 1991). Short term and on-going training and program development were offered to hundreds of treatment providers at both state and local mental health and substance abuse agencies. Consumer led and family support programs were also developed. The state produced a training video that demonstrated the integrated treatment model. The CQC report called for "invested," "sustained," leadership. However, the training site closed in 1990 due to budgetary considerations. MICA programs and groups that grew out of this model continue to be an important nucleus of our present services in New York State and nationally.

The original treatment interventions evolved in "adaptation" to the needs of MICA clients. Methods and philosophies clearly differed from traditional substance abuse treatment. Consumers who were actively abusing substances, physically addicted, unstable, and unmotivated (Sciacca 1987a, 1991) were engaged into treatment. A "non-confrontational" approach to denial and resistance, involving acceptance of all symptoms was employed. Consumers participated in treatment groups without pressure to self disclose, and explored topics from their own perspectives. Subsequent providers either learned from this model, or came upon similar processes through their own experimentation. Presently, we find consistent similarities across the interventions that have evolved for the dually diagnosed, thereby validating the need for new treatment models.

The process of "interagency" program development implemented in 1985 (Sciacca, 1987b) has escalated in the state of Michigan. A project that included formal cross-training and cross-systems program development was jointly initiated by the split bureaus (Sciacca & Thompson, 1996) in 1993. It demonstrated that continuity of care across systems, including trained professionals from a variety of disciplines, is attainable and results in improved, less costly services for the dually diagnosed. Every program in both service delivery systems (across two counties) was included. This project is yet to be replicated.

In the Journal special section, Green (1996) diagrams for us the serious inadequacies of our divided systems, and the resulting deterioration and anguish for the consumer. In contrast, her participation in an integrated dual diagnosis program that was accepting of all of her symptoms led to her attainment of sobriety and stability.

Our history thus far demonstrates a lack of invested, sustained leadership that is capable of developing a cohesive national agenda for dual disorders. It is our respsonsibility to change the course of this history to meet the needs of dually diagnosed consumers and their families ( Sciacca & Hatfield, 1995).

References:
Drake,R.E.,Mueser,K.T.,Clark,R.E.,&Wallach,M.A.(1996) The course,treatment and outcome of substance disorder in persons with severe mental illness. American Journal of Orthopsychiatry.(66),42-51.
Gigliotti,Marcus,(1986,October-November) Program Initiatives for Dually Diagnosed at Harlem Valley P.C. Quality of Care Newsletter by the N.Y.S. Commission on Quality of Care. Issue 28, p.9
Gorman,Christine,(1987, August 3)"Bad Trips for the Doubly Troubled" TIME Magazine, pg.58.
Green,V.L.(1996)The resurrection and the life. American Journal of Orthopsychiatry,66,12-16.
Osher,F.C. & Drake,R.E.(1996) Reversing a history of unmet needs: Approaches to care for persons with co-occurring addictive and mental disorders. American Journal of Orthopsychiatry,66, 4-11.
Ridgely MS, Osher FC, & Talbott JA, (1987)"Chronic Mentally Ill young adults with substance abuse problems: Treatment and Training issues. Baltimore Mental Health Policy Studies, University of Maryland School of Medicine.
Sciacca, K.,(1987a,July)"New Initiatives in the Treatment of the Chronic Patient with Alcohol/Substance Use Problems." TIE Lines, Vol.IV, No. 3. (Publication of the Information Exchange of Young Adult Chronic Patients.)
Sciacca, K., (1987b)"Alcohol and Substance Abuse Programs at New York State Psychiatric Centers Develop and Expand." This Month in Mental Health, NYSOMH, Vol.10, No.2, pg.6,& AID Bulletin Addiction Intervention with the Disabled, Winter Vol.9, No.2, p.1-3.
Sciacca, K., (1991,Summer) "An Integrated Treatment Approach for Severely
Mentally Ill Individuals with Substance Disorders." New Directions for Mental Health Services, Dual Diagnosis of Major Mental Illness and Substance Disorders. (Jossey-Bass Publishers, #50.)
Sciacca, K. & Hatfield, A.B.,(1995) "The Family and the Dually Diagnosed Patient." Double Jeopardy, Ed.Lehman,A.A.,& Dixon,L.P., Harwood Academic Publishers, Chapt.12, pp.193-209.
Sciacca, K. & Thompson, C.M.,(1996,Summer) "Program Development and Integrated Treatment Across Systems for Dual Diagnosis: Mental Illness, Drug Addiction and Alcoholism, MIDAA." The Journal of Mental Health Administration, Vol.23, No.3.
Sundram, CJ, Platt, IL, Cashen, JA,(1986,September)"The Multiple Dilemmas of the Multiply Disabled." Albany, NYS Commission on Quality of Care for the Mentally Disabled report.

Copyright, 1996 Kathleen Sciacca