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On Co-occurring Addictive and Mental Disorders: A Brief History of the Originsof Dual Diagnosis Treatment and Program Development
 
By: Kathleen Sciacca, M.A.
Executive Director, Sciacca Comprehensive Service Developmentfor Mental Illness, Drug Addiction and Alcoholism, MIDAA, e-mail: ksciacca@pobox.comURL: http://pobox.com/~dualdiagnosisInvited response to section on co-occurring addictive and mental disorders. Published letter tothe 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 thehistory of separating mental health and addictive services, is an important contribution to theliterature on dual disorders. Since we are now in the early stages of the evolution of dualdiagnosis services, however, I believe it is important to provide a more complete and detailedaccount of the previous initiatives in this field.In response to the article by Drake, Mueser, Clark and Wallach (1996) which states "Ten yearsago the only treatment options available for people with co-occurring substance abuse and severemental illness were parallel treatments in separate programs" (p.49), the record requirescorrection. Dual diagnosis treatment interventions and "integrated" programs that truly adaptedto 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 theseintegrated treatment programs were implemented across multiple program sites (Sciacca,1987b).Concurrently, treatment and program elements were taught through training seminars in NewYork as well as nationally. Early articles by Gigliotti, 1986 and Sciacca, 1987a, 1987b, outlinedthese 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 downwardspiral of dually diagnosed consumers who were bounced among different systems with "nodefinitive 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 thispopulation. CQC proceeded to visit the dual diagnosis programs developed in 1984, and declaredthe treatment interventions, the training, and integrated programs to be positive solutions to thedilemmas (Gigliotti, 1986). TIME magazine learned of the CQC report, and CQC suggested thatTIME magazine investigate these programs. A reporter sat in on treatment groups, interviewedconsumers 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 dualdiagnosis statistics (Ridgely, Osher, & Talbott, 1987). Hence, the "doubly troubled" werebrought to the attention of the general public.The Governor's task force put forward a vision for statewide program development. The "MICATraining Site for Program and Staff Development, New York Statewide" was created to attainthat vision (Sciacca 1987b, 1991). Short term and on-going training and program developmentwere offered to hundreds of treatment providers at both state and local mental health andsubstance abuse agencies. Consumer led and family support programs were also developed. Thestate produced a training video that demonstrated the integrated treatment model. The CQCreport called for "invested," "sustained," leadership. However, the training site closed in 1990due to budgetary considerations. MICA programs and groups that grew out of this modelcontinue 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, andunmotivated (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 topicsfrom their own perspectives. Subsequent providers either learned from this model, or came uponsimilar processes through their own experimentation. Presently, we find consistent similaritiesacross the interventions that have evolved for the dually diagnosed, thereby validating the needfor new treatment models.The process of "interagency" program development implemented in 1985 (Sciacca, 1987b) hasescalated 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 trainedprofessionals from a variety of disciplines, is attainable and results in improved, less costlyservices for the dually diagnosed. Every program in both service delivery systems (across twocounties) was included. This project is yet to be replicated.In the Journal special section, Green (1996) diagrams for us the serious inadequacies of ourdivided systems, and the resulting deterioration and anguish for the consumer. In contrast, herparticipation in an integrated dual diagnosis program that was accepting of all of her symptomsled to her attainment of sobriety and stability.
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