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Program Development and Integrated Treatment Across Systemsfor Dual Diagnosis: Mental Illness, Drug Addiction AndAlcoholism, MIDAA*
 Authors: Kathleen Sciacca, M.A Christina M. Thompson, Ph.D.
Address correspondence to:Kathleen Sciacca, M.A.Executive DirectorSciacca Comprehensive Service Development for MIDAA299 Riverside DriveNew York, N. Y. 10025Tel. 212-866-5935E-mail: ksciacca@pobox.com
 
 Journal of Mental Health Administration
, Vol.23, No.3, pgs. 288-297,Summer 1996.
Abstract
 
 Numerous Bureaus of mental health, drug addiction, and alcoholism aredesignated 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 methodsacross the systems have resulted in minimal services for persons with dualdiagnosis. 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 eachdelivery 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 personswith dual diagnosis is greatly improved.
In 1986, The New York State Commission on the Quality of Care for theMentally Disabled found that 50% of the patients admitted for psychiatric careacross New York State also had alcohol and substance abuse that requiredtreatment.
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 withsevere mental illness abuse illicit drugs or alcohol as compared to 15% of thegeneral population.
2
Other studies in 1993 have shown that 90% of prisoners witha 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 andsubstance disorders, and the serious consequences, facilities that providecomprehensive services for dual/multiple disorders are limited as compared toservices for singular disorders.Mental health and substance abuse providers alike encounter difficulties inaccessing comprehensive services for dually-diagnosed clients. The underlyingreasons include the following:1.
 
Bureaucracies are divided according to individual categories of disorderswith segregated admissions criteria, treatment programs, services andreimbursement;2.
 
providers are educated and trained to deliver services for single, discretedisorders only;
6
and,3.
 
treatment approaches across these disorders are incompatible and differ inmethod and philosophy.
7
 The project the authors have initiated addresses each of the three underlyingissues outlined above. In this article the authors will discuss a model of programdevelopment that has integrated the mental health and substance abuse systems inthe Jackson-Hillsdale counties of Michigan. The authors will review program andstaff development accomplished through an interagency process of cross-trainingand program implementation.
7,8
This has resulted in comprehensive services atmultiple sites within the mental health and substance abuse service deliverysystems. This will be followed by an overview of a non-confrontational treatmentmodel
7
and accompanying philosophy developed specifically for persons whohave dual disorders.
Assessment of Service Needs
 Following a critical suicide attempt in April 1991, the Jackson-HillsdaleCommunity Mental Health Board Chief Executive Officer and the ExecutiveDirector of the South Central Michigan Substance Abuse Commission (a regionalauthority), reviewed statistics on substance abusing clients who also presentedthemselves in psychiatric crisis. The community mental health center provided24-hour, 7-day a week emergency services which included face-to-faceassessment of persons entering the emergency room at the general hospital. Amajor focus of this assessment was to determine the need for inpatient psychiatriccare or other alternative treatment services. The Michigan Mental Health Code
9
 specifies that to be elegible for inpatient care individuals must be severelymentally ill and a danger to self/others/unable to care for their basic needs. TheMichigan Public Health Code also states that emergency rooms must offer
 
treatment for incapacitated persons taken into protective custody by a lawenforcement officer.
10
Hospitals under Federal EMTALA (Emergency MedicalTreatment and Labor Act) standards were concerned about screening, admissionand discharge issues for these persons. EMTALA defines the conditions fortreatment as those medical conditions which manifest acute symptoms of sufficient severity that the absence of immediate medical attention couldreasonably result in placing the individual in serious jeopardy. Hospitals wereprohibited from transferring or discharging patients with emergency conditionsuntil stabilized.Increasingly, the community mental health staff who performed the generalhospital emergency room assessments were seeing intoxicated individuals withsuicidal/homicidal ideation. Generally the individuals were held in the emergencyroom. 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 toApril, 1991 forty-seven of fifty-five emergency room assessments revealed nonecessity for psychiatric inpatient care based upon admission criteria in theMichigan Mental Health Code. Twelve of these individuals were recidivists to theemergency room, and fifteen were admitted to short term (2-3 day) psychiatricinpatient care for observation despite lack of an appropriate psychiatric diagnosis.These same fifteen clients were rejected for substance abuse residential treatmentand their recidivism led them to become known as "revolving door" consumers.In the absence of acute symptoms of severe mental illness, and with a stabilizedmedical condition, clients were discharged from the emergency room. Thissituation posed a fear and major concern for both treatment systems and thegeneral hospital.The substance abuse agency, the community mental health agency and the generalhospital were concerned about service delivery gaps and liability relative toabandonment issues. In addition, the parties recognized the need to connectindividuals with ongoing treatment as soon as possible during the crisis periodssince it was believed that effecting change is easier during such periods.In 1992, a separate and independent report about the general hospital yielded thefollowing data.
11
From October 1991 to September 1992, seven psychiatristsordered 87 alcohol and drug consults on a total of 79 patients (eight consults wererepeated on the same patients during separate episodes). There were 82 consultson the inpatient mental health units, two consults were main hospital patients andthree were outpatient mental health patients. This number comprises 53 males(60.9%) and 34 females (38.6%). The substance disorder diagnosis wasconfirmed through a series of screening tests and a face to face interview. Seventysix of the 79 patients assessed (or 96.2%) met the criteria for alcohol and/or drugdependence. This number constitutes only 8.3% of the total hospital admissionsfor that year. The report concluded that "dual diagnosis" case finding would be
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