Program Development and Integrated Treatment Across Systems

for Dual Diagnosis: Mental Illness, Drug Addiction And

Alcoholism, MIDAA*

Authors: Kathleen Sciacca, M.A Christina M. Thompson, Ph.D.

Address correspondence to:

Kathleen Sciacca, M.A.

Executive Director
Sciacca Comprehensive Service Development for MIDAA
299 Riverside Drive
New York, N. Y. 10025
Tel. 212-866-5935
E-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 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:

1. Bureaucracies are divided according to individual categories of disorders

with segregated admissions criteria, treatment programs, services and
reimbursement;
2. providers are educated and trained to deliver services for single, discrete
disorders only;6 and,
3. treatment approaches across these disorders are incompatible and differ in
method and philosophy.7

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.

Staff Selection
Program development is optimal when staff "self elect" to participate in this
process of program development. Staff who are motivated to enhance their
education, training and clinical experience participate enthusiastically.
Participants are expected to learn about disorders they are unfamiliar with, and to
educate their clients about these disorders. At times teaching and learning may be
simultaneous. Providers are not expected to be experts in both fields. The
treatment model includes an exploratory approach to learning with and from the
clients about dual disorders. It is important for staff to understand that they are
"agents of change" within their program and the larger system. A benefit of inter-
agency training is that often it serves as a professional support group.

Content of Cross-Training and Program Implementation

At the onset, bringing providers from both systems together to achieve
cooperation, shared learning, and the attainment of a mutual goal was a unique
experience. The on-going program development project included day-long
training sessions held once a month over the course of ten months. This allowed
for program implementation and the provision of MIDAA treatment services
concurrent with training and supervision over time. Each participant received
individual supervision for step by step implementation of a dual diagnosis service
track at their specific program site. The program forms in the MIDAA Service
Manual were utilized by each participant and served as both training and program
materials. Participants were initially familiarized with the treatment model and the
program materials during the introductory seminar. The on-going monthly
sessions provide in-depth training and supervision for the experiential application
of all aspects of MIDAA treatment and service provision at the respective sites.

Working Definitions of MIDAA Profiles

Participants were provided with working definitions of three client profiles found
within MIDAA dual/multiple disorders.7 "MICAA" Mental Illness; Chemical
Abuse; and Addiction: clients who have an Axis I16 diagnosis of severe, persistent
mental illness that is free standing of substance disorders, yet co-occurring with
substance abuse or dependence. MICAA clients usually require prescribed
medication for their mental health symptoms. "CAMI" denotes Chemical Abusing
Mentally Ill. CAMI clients have substance disorders, and may also have mental
illness on the Axis II, personality disorders. A subgroup of the "CAMI" client
profile is the client who in addition, experiences "substance induced" psychotic
episodes. This client often utilizes psychiatric emergency services, community
mental health, and substance abuse services. Clients with this profile may be
inaccurately re-defined as "MICAA" to the disservice of their treatment needs.
Another distinction is clients with organic symptoms resulting from chronic
substance abuse, or other causes. Such organic symptoms may be found in clients
with either the MICAA or CAMI profile, and their service needs may differ. All
diagnoses are based upon criterion in the DSM 111-R,16 and DSM IV17 diagnostic
manuals. Many clients enter into dual disorder services with a principle diagnosis
that is in keeping with the service system. In the mental health system, the
substance disorder often has not been diagnosed. MIDAA staff learn to diagnose
substance disorders using some of the information obtained in the comprehensive
assessment.13

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.

Figure 1
Sciacca Treatment Model for Dual Diagnosis (MIDAA)

PROGRAM FORM and/or PROCESS AND OUTCOME

INTERVENTION
1. Screening: Mental health, D.D.
CAGE. Substance Abuse, MISF.
2. Pre-group interview and
readiness scale. Engagement. ;
3. Continuation of engagement
(when applicable).
4. Provide group treatment.
Identification of potential clients with dual
diagnosis.
a. Engagement into group treatment
b. assessment of readiness level.(1-5).
Client requires engagement beyond pre-
group interview

Phase 1: client does not disclose personal

5. Complete monthly data form for
each group.
6. Administer comprehensive
assessment (phase two).
a. integrate information into
treatment plan.
b. make diagnosis.
7. Client progress review updated
periodically, includes readiness
scale.
8. Client continues in treatment
and/or relapse prevention. May
include outside services.
situation, participates in discussions of
educational materials/ topics, develops trust
Phase 2: a.Client discusses own substance
abuse/mental health.
Continuation of phase 2:
b. client identifies adverse effects, and/or
interactions between dual disorders.
c. client recognizes impact of symptoms
upon well being.
Phase 3: a.Client becomes motivated for
treatment.
b. client actively engages in treatment and
symptom management until stability and/or
remission is achieved.
 c. client participates in relapse prevention.

Source: Sciacca.7
Note: MIDAA = Mental Illness, Drug Addiction, and Alcoholism; DD CAGE =
Dual Diagnosis CAGE Questionnaire; MISF = Mental Illness Screening Form.

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

Extensive and integral training was provided in the use of a "non-confrontational"
treatment approach and consistent philosophy. The philosophy and the treatment
approach inherent in the comprehensive service model7 were adopted by both care
systems. Each program element of both care systems included groups specifically
designed to address the needs of persons with dual/multiple diagnosis of MIDAA.

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:

a) Assessment/Evaluation, 8 of 11 respondents M.H., 2 of 4

respondents S.A.;
b) Engagement of clients at various stages of readiness, 8 of 11
respondents M.H., 3 of 4 respondents S.A.;
c). Use of educational materials in MIDAA groups, 10 of 11
respondents M.H., 2 of 4 respondents S.A.;
d). Indicators of client progress, 3 of 11 respondents M.H., 2 of 4
respondents, S.A.

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.

Summary

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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This complete article is included in a packet of articles that is available
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Copyright ©1996 Kathleen Sciacca

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