On Co-occurring Addictive and Mental Disorders: A Brief History of the Origins

of Dual Diagnosis Treatment and Program Development

By: Kathleen Sciacca, M.A. Executive Director, Sciacca Comprehensive Service Development
for Mental Illness, Drug Addiction and Alcoholism, MIDAA, 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

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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.

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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.

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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 responsibility 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.

Issue28,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,UniversityofMarylandSchoolofMedicine.

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

ExchangeofYoungAdultChronicPatients.)

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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