The Mental Health System

Actually, there is no single mental health system, although most States have a set of public mental health centers. Rather, mental health services are provided by a variety of mental health professionals including psychiatrists; psychologists; clinical social workers; clinical nurse specialists;other therapists and counselors including marriage, family, and child counselors (MFCCs); and paraprofessionals.

These mental health personnel work in a variety of settings, using a variety of theories about the treatment of specific psychiatric disorders. Different types of mental health professionals (for example, social workers and MFCCs) have differing perspectives; moreover, practitioners within a given group often use different approaches.

A major strength of the mental health system is the comprehensive array of services offered, including counseling, case management, partial hospitalization, inpatient treatment, vocational rehabilitation, and a variety of residential programs. The mental health system has a relatively large variety of treatment settings. These settings are designed to provide treatment services for patients with acute, subacute, and long-term symptoms. Acute services are provided by personnel in emergency rooms and hospital units of several types and by crisis-line personnel, outreach teams, and mental health law commitment specialists. Subacute services are provided by hospitals, day treatment programs, mental health center programs, and several types of individual practitioners. Long-term settings include mental health centers, residential units, and practitioners' offices. Clinicians vary with regard to academic degrees, styles, expertise, and training. Another strength of the mental health system is the growing recognition at all system levels of the role of case management as a means to individualize and coordinate services and secure entitlements.

Medication is more often used in psychiatric treatment than in addiction treatment, especially for severe disorders. Medications used to treat psychiatric symptoms include psychoactive and nonpsychoactive medications. Psychoactive medications cause an acute change in mood, thinking, or behavior, such as sedation, stimulation, or euphoria.

Psychoactive medications (such as benzodiazepines) prescribed to the average patient with psychiatric problems are generally taken in an appropriate fashion and pose little or no risk of abuse or addiction. In contrast, the use of psychoactive medications by patients with a personal or family history of an AOD use disorder is associated with a high risk of abuse or addiction.

Some medications used in psychiatry that have mild psychoactive effects (such as some tricyclic antidepressants with mild sedative effects) appear to be misused more by patients with an AOD disorder than by others. Thus, a potential pitfall is prescribing psychoactive medications to a patient with psychiatric problems without first determining whether the individual also has an AOD use disorder.

While most clinicians in the mental health system generally have expertise in a biopsychosocial approach to the identification, diagnosis, and treatment of psychiatric disorders, some lack similar skills and knowledge about the specific drugs of abuse, the biopsychosocial processes of abuse and addiction, and AOD treatment, recovery, and relapse.Similarly, AOD treatment professionals may have a thorough understanding of AOD abuse treatment but not psychiatric treatment.

The Addiction Treatment System

As with mental health treatment, no single addiction treatment system exists. Rather, there is a collection of different types of services such as social and medical model detoxification programs, short- and long-term treatment programs, methadone detoxification and maintenance programs, long-term therapeutic communities, and self-help adjuncts such as the 12-step programs. These programs can vary greatly with respect to treatment goals and philosophies.For example, abstinence is a prerequisite for entry into some programs, while it is a long-term goal in other programs. Some AOD treatment programs are not abstinence oriented. For example, some methadone maintenance programs have the overt goal of eventual abstinence for all patients, while others promote continued methadone use to encourage psychosocial stabilization.

As with mental health treatment, addiction treatment is provided by a diverse group of practitioners, including physicians, psychiatrists, psychologists, certified addiction counselors, MFCCs, and other therapists, counselors, and recovering paraprofessionals. There can be a wide difference in experience, expertise, and knowledge among these diverse providers. As with mental health treatment, most States have public and private AOD treatment systems.

The strengths of addiction treatment services include the multidisciplinary team approach with a biopsychosocial emphasis, and an understanding of the addictive process combined with knowledge of the drugs of abuse and the 12-step programs. In typical addiction treatment, medications are used to treat the complications of addiction, such as overdose and withdrawal.However, few medications that directly treat or interrupt the addictive process, such as disulfiram and naltrexone, have been identified or regularly used.Maintenance medications such as methadone are crucial for certain patients.However, most addiction treatment professionals attempt to eliminate patients' use of all drugs.

Many who work in the addiction treatment field have only a limited understanding of medications used for psychiatric disorders. Historically, some people have mistakenly assumed that all or most psychiatric medications are psychoactive or potentially addictive. Many addiction treatment staff tend to avoid the use of any medication with their patients, probably in reaction to those whose addiction included prescription medications such as diazepam (Valium). Many staff have a lack of training and experience in the use of such medications. In the treatment of dual disorders, a balance must be made between behavioral interventions and the appropriate use of nonaddicting psychiatric medications for those who need them to participate in the recovery process. Withholding medications from such individuals increases their chances of AOD relapse.

An important adjunct to addiction treatment services is the massive system of consumer-developed groups, such as the 12-step program of Alcoholics Anonymous (AA). Participants in AA and other self-help groups (Narcotics Anonymous [NA], Cocaine Anonymous [CA], etc.) can provide needed support and encouragement for patients in treatment.Importantly, these services are widespread nationally and internationally.While self-help programs are not considered treatment per se, they are integral adjuncts to professional treatment services.

However, patients in self-help groups may give others inappropriate advice regarding medication compliance, based on personal experience, fears of medication, or incomplete knowledge about the role of medication in dual disorders. In many urban areas, there are specialized 12-step groups for people with dual disorders. In these so-called "Double Trouble" meetings, medication compliance is a part of "working the program."

The Medical System

Primary health care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with psychiatric and AOD use disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to psychiatric and substance use disorders. And because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with psychiatric and AOD disorders.

However, physicians -- especially primary care physicians -- are able to devote very little time to eachpatient. Pressured for time, these physicians may prescribe such psychiatric medications as antidepressants or anxiolytics or medication such as disulfiram or naltrexone as a primary approach, rather than as an adjunctive approach. Indeed, primary care physicians are the largest single prescriber of antianxiety medications.Some of these medications, such as the benzodiazepines, are psychoactive and can be abused.

Also, physicians and nurses have historically been trained to focus on the medical consequences of addiction, such as withdrawal, overdose, or hepatitis, without assessing, treating, or actively referring the individual for treatment of the addiction itself. The role of physicians with regard to addiction is changing through the leadership of national organizations such as the American Society of Addiction Medicine, the American Academy of Psychiatrists on Alcohol and Addiction, and the Association of Medical Education and Research on Substance Abuse. Similar groups exist for nurses and allied health care professionals. Such groups can provide medical professionals with important information and education about the biopsychosocial nature of addiction and treatment, especially regarding patients with dual disorders.

Differing Approaches: Individual Responsibility and Treatment Focus

Traditionally, patients in mental health settings have had the responsibility of getting themselves to treatment services and appointments as a sign of treatment motivation. More recently, and in recognition that many severely mentally ill patients are unwilling or unable to use traditional community-based services, the mental health field has emphasized the role of case management. Case management (also called care management) can help to engage, link, and support patients in needed community services. Case management can help to reduce the negative consequences to the individual from lack of followup and participation in treatment. Without case management, many severely ill patients would decompensate, need to be hospitalized, or become homeless.

The case management model identifies individual limitations, deficits, and strengths and aggressively attempts to provide patients with what they need. When a patient rejects professional assistance, the case manager assumes the responsibility for finding a different way to get the individual to accept assistance. The case manager may minimize the negative consequences to the individual in order to engage or maintain the patient in treatment. Thisactivity might be seen as "enabling" by traditional addiction treatment personnel.

In contrast, the addiction treatment system focuses on individual responsibility, including the responsibility of accepting help. Motivation for recovery is enhanced through confrontation of the adverse consequences of addiction. Further, addiction intervention and treatment involve diminishing the individual's denial about the presence and severity of the addiction through direct but therapeutic confrontation of examples of addiction-related behaviors. Thus, traditionally, patients in the addiction treatment system who did not want help or could not tolerate confrontation might not get help. Mental health personnel might regard this situation as an abandonment of the most needy. More recently, the addiction treatment system has been developing case management models to better address treatment-resistant patients.

Treatment of patients with dual disorders must blend both mental health and AOD treatment models, with each applied at appropriate times and in appropriate situations according to patients' needs. There should be a balance between clinician and patient acceptance of responsibility for treatment and recovery from dual disorders.

For example, in AOD treatment, clinical staff and fellow patients often aggressively confront patients who deny that they have an AOD problem or who minimize the severity of their problem. However, treatment of individuals with dual disorders first requires innovative approaches to engage them in treatment as a prerequisite to confrontation. The role of confrontation may need to be substantially modified, particularly in the treatment of disorganized or psychotic patients, who may tolerate confrontation only in later stages of treatment (when their symptoms are stable and they are engaged in the treatment process).

In addiction treatment, the focus is often on the "here and now," while in mental health treatment, the focus is often on past developmental issues. Mental health practitioners may identify AOD abuse as a symptom of a prior trauma rather than an illness in its own right.The focus of treatment may be on the developmental issues, with the assumption that the AOD use disorder will improve automatically once these issues are treated.Inadvertently, the mental health therapist can enable AOD use to continue.

The Role of Abstinence

Within parts of the addiction treatment system, abstinence from psychoactive drugs is a precondition to participate in treatment. For the more severely illpatients with dual disorders (such as patients with schizophrenia), abstinence from AODs is often considered a goal, possibly a long-term goal, similar to the approach at some methadone maintenance programs. On the other hand, treatment of less severe dual psychiatric conditions, such as depression or panic disorder, should require AOD abstinence, since AOD use compromises both diagnosis and treatment (see individual chapters).

For some patients with dual disorders, requiring abstinence as a condition of entering treatment may hinder or discourage engagement in the treatment process. For these patients, abstinence may be redefined as a goal, with encouragement provided for incremental steps in the reduction of amount and frequency of drug use. For example, patients who experience homelessness and housing instability likely do not live in drug-free environments. For such patients, it may be unrealistic to mandate abstinence as a requirement for treatment. Exhibit 3-1 describes some of the treatment strategy differences for managing patients in mental health, addiction, and dual disorder treatment approaches.

Sequential Treatment

The first and historically most common model of dual disorder treatment is sequential treatment. In this model of treatment, the patient is treated by one system (addiction or mental health) and then by the other. Indeed, some clinicians believe that addiction treatment must always be initiated first, and that the individual must be in a stage of abstinent recovery from addiction before treatment for the psychiatric disorder can begin. On the other hand, other clinicians believe that treatment for the psychiatric disorder should begin prior to the initiation of abstinence and addiction treatment. Still other clinicians believe that symptom severity at the time of entry to treatment should dictate whether the individual is treated in a mental health setting or an addiction treatment setting or that the disorder that emerged first should be treated first.

The term sequential treatment describes the serial or nonsimultaneous participation in both mental healthand addiction treatment settings. For example, a person with dual disorders may receive treatment at a community mental health center program during occasional periods of depression and attend a local AOD treatment program following infrequent alcoholic binges. Systems that have developed serial treatment approaches generally incorporate one of the above orientations toward the treatment of patients with dual disorders.

Parallel Treatment

A related approach involves parallel treatment:the simultaneous involvement of the patient in both mental health and addiction treatment settings. For example, an individual may participate in AOD education and drug refusal classes at an addiction treatment program, participate in a 12-step group such as AA, and attend group therapy and medication education classes at a mental health center. Both parallel and sequential treatment involve the utilization of existing treatment programs and settings. Thus, mental health treatment is provided by mental health clinicians, and addiction treatment is provided by addiction treatment clinicians. Coordination between settings is quite variable.

Integrated Treatment

A third model, called integrated treatment, is an approach that combines elements of both mental health and addiction treatment into a unified and comprehensive treatment program for patients with dual disorders. Ideally, integrated treatment involves clinicians cross-trained in both mental health and addiction, as well as a unified case management approach, making it possible to monitor and treat patients through various psychiatric and AOD crises.

There are advantages and disadvantages in sequential, parallel, and integrated treatment approaches. Differences in dual disorder combinations, symptom severity, and degree of impairment greatly affect the appropriateness of a treatment model for a specific individual. For example, sequential and parallel treatment may be most appropriate for patients who have a very severe problem with one disorder, but a mild problem with the other. However, patients with dual disorders who obtain treatment from two separate systems frequently receive conflicting therapeutic messages; in addition, financial coverage and even confidentiality laws vary between the two systems.

In contrast, integrated treatment places the burden of treatment continuity on a case manager who is expert in both psychiatric and AOD use disorders.Further, integrated treatment involves simultaneous treatment of both disorders in a setting designed to accommodate both problems.

Treatment Engagement

In general, treatment engagement refers to the process of initiating and sustaining the patient's participation in the ongoing treatment process. Engagement can involve such enticements as providing help with the procurement of social services, such as food, shelter, and medical services. Engagement can also involve removing barriers to treatment and making treatment more accessible and acceptable, for example, by providing day and evening treatment services. Engagement can be enhanced by providing adjunctive services that may appear to be indirectly related to the disorders, such as child care services, job skills counseling, and recreational activities.It may also be coercive, such as through involuntary commitment or a designated payee.

Engagement begins with efforts that are designed to enlist people into treatment, but it is a long-term process with the goals of keeping patients in treatment and helping them manage ongoing problems and crises. Essential to the engagement process is: 1) a personalized relationship with the individual, 2) over an extended period of time, with 3) a focus on the stated needs of the individual.

For patients with dual disorders, engagement in the treatment process is essential, although the techniques used will depend upon the nature, severity, and disability caused by an individual's dual disorders. An employed person with panic disorder and episodic alcohol abuse will require a different type of engagement than a homeless person with schizophrenia and polysubstance dependence. Withrespect to severe conditions such as psychosis and violent behaviors, therapeutic coercive engagement techniques may include involuntary detoxification, involuntary psychiatric treatment, or court-mandated acute treatment.

Treatment Continuity

To treat patients with dual disorders, it is critical to develop continuity between treatment programs and treatment components, as well as treatment continuity over time. In practice, many patients participate in treatment at different sites. Even in integrated treatment programs, many patients require different treatment services during different phases of treatment.For this reason, treatment should include an integrated dual disorder case management program, which can be located within a mental health setting, an addiction treatment setting, or a collaborative program.

Treatment Comprehensiveness

An overall system for treating dual disorders includes mental health and addiction treatment programs, as well as collaborative integrated programs. Programs should be designed to: 1) engage clients, 2) accommodate various levels of severity and disability, 3) accommodate various levels of motivation and compliance, and 4) accommodate patients in different phases of treatment. There should be access to abstinence-mandated programs and abstinence-oriented programs, as well as to drug maintenance programs.Different levels of care, ranging from more to less intense treatment, should be available.

Phases of Treatment

In general, the medical term acute describes phenomena that begin quickly and require rapid response. Acute problems are contrasted with chronic problems. Most commonly, acute stabilization of patients with dual disorders refers to the management of physical, psychiatric, or drug toxicity crises. These include injury, illness, AOD-induced toxic or withdrawal states, and behavior that is suicidal, violent, impulsive, or psychotic.

The acute stabilization of AOD use disorders typically begins with detoxification, such as inpatient detoxification for patients with significant withdrawal or outpatient detoxification for mild to moderate withdrawal, as well as nonmedical withdrawal, such as occurs in social-model detoxification programs. Also, initiation of methadone maintenance can provide outpatient acute stabilization for patients addicted to opioids.

Acute stabilization of psychiatric symptoms more frequently occurs within a mental health or emergency medical setting, but involves a range of treatment intensity.Patients with severe symptoms, especially psychotic, violent, or impulsive behaviors, usually require acute psychiatric inpatient treatment and psychiatric medications, while patients with less severe symptoms can be treated in outpatient or day treatment settings.

Dual disorder programs that provide stabilization to patients with acute needs should have the capability to:

• Identify medical, psychiatric, and AOD use disorders
• Treat a range of illness severity
• Provide drug detoxification, psychiatric medications, and other biopsychosocial levels of treatment
• Provide a range of intensities of service.

These programs should be capable of promoting the patient's engagement with the treatment system. They should be able to aggressively provide linkages to other programs that will provide ongoing treatment and engagement.

Subacute Stabilization

The medical term subacute describes the status of a medical disorder at points between the acute condition and either resolution or chronic state. The subacute phase of a medical problem occurs as the acute course of the problem begins to diminish, or when symptoms emerge or reemerge but are not yet severe enough to be described as acute.

For example, patients recently detoxified from AODs frequently experience subacute symptoms such as insomnia and anxiety that may linger for a few days or weeks. On the other hand, recently detoxified patients with dual disorders may experience subacute symptoms of insomnia and anxiety either as subacute withdrawal symptoms or as a prelude to relapse with depression. Although the subacute phase is not generally regarded as a period of crisis, ignoring these symptoms and failing to assess and treat them may lead to symptom escalation, decompensation, and relapse.

As AOD-induced toxic or withdrawal symptoms resolve, constant reassessment and rediagnosis is required. During this phase, a psychoeducational and behavioral approach should be used to educate patients about their disorders and symptomatology.During this phase, treatment providers should provide assessment and planning for dealing with long-term issues such as housing, long-term treatment, and financial stability.

Biopsychosocial Assessment Issues From the AOD and Psychiatric Perspectives

ABC Model for Psychiatric Screening

• Appearance, alertness, affect, and anxiety:

  Appearance:

  General appearance, hygiene, and dress.

  Alertness:

  What is the level of consciousness?

  Affect:

  Elation or depression: gestures, facial expression, and speech.

  Anxiety:

  Is the individual nervous, phobic, or panicky?

• Behavior:

  Movements:

  Rate (Hyperactive, hypoactive, abrupt, or constant?).

  Organization:

  Coherent and goal-oriented?

  Purpose:

  Bizarre, stereotypical, dangerous, or impulsive?

  Speech:

  Rate, organization, coherence, and content.

• Cognition:

  Orientation:

  Person, place, time, and condition.

  Calculation:

  Memory and simple tasks.

  Reasoning:

  Insight, judgment, problem solving.

  Coherence:

  Incoherent ideas, delusions, and hallucinations?

Long-Term Stabilization

The treatment settings for long-term treatment, rehabilitation, and recovery from dual disorders include outpatient, day treatment, and residential settings. Ideally, treatment intensity is dictated by disorder severity and motivation for treatment, as well as by personal and local treatment resources. In more severe conditions, ongoing dual disorder case management is essential. The management of long-term severe conditions is described in more detail in the chapter on psychotic disorders (Chapter 8).

With regard to the initiation and maintenance of sobriety in patients with dual disorders, another way of looking at acute, subacute, and long-term phases involves a four-step approach that leads to abstinence. This approach is particularly important for patients with severe psychiatric problems and an AOD use disorder (Minkoff and Drake, 1991; Ries, 1993a).

Psychiatric and AOD abuse treatment issues are woven into the groups in such a way that concreteissues (such as medication compliance) are addressed in persuasion groups, while abstract concepts (such as self-image) are addressed in active treatment or abstinence support groups. Some patients -- such as severely psychotic patients -- may not be able to advance beyond persuasion groups or active treatment groups.

Areas of Primary Concern

To establish and maintain linkages among the various systems working with patients who have dual disorders, several primary administrative areas need to be examined.

It is beyond the scope of this document to provide detailed discussion of each area, but the following discussion of problems and solutions will help readers in their problem solving. The areas to be discussed in this chapter include:

• Policy and planning structures
• Funding and reimbursement
• Data collection and needs assessment
• Program development
• Screening, assessment, and referral
• Case management
• Staffing issues
• Training and staffing
• Linkages with social services agencies
• Linkages with the medical health care system
• Linkages with the criminal justice system.

Problems

Often there is little or no communication or collaboration among various departments and levels of government that have separate administrative structures, constituencies, mandates, and target groups.There are also different Federal, State, and local planning cycles within the AOD use and mental health treatment systems.

The Federal Government requires two separate planning processes for programs receiving Federal funds: A State mental health plan and a State substance abuse plan. The federally mandated State planning processes required under the Public Health Service Act for mental health treatment and AOD abuse treatment are separate and have no requirements for coordination.

Solutions

Amendments are needed to the Public Health Service Act to encourage coordinated long-term planning between the State mental health and AOD abuse treatment systems for patients with dual disorders.

The development and use of long-term structural mechanisms (such as coordinating bodies, task forces, memoranda of understanding, and letters of agreement) can help improve planning for andintegration of services for patients who have dual disorders.

To accomplish this goal, States might create a joint planning mechanism -- an officially organized planning group -- that would: 1) have diverse composition, 2) carry out specific types of tasks, and 3) maintain specific foci.

Problems

Because of diminishing fiscal resources and competition among many interest groups for particular types of treatment, those who seek funds for the treatment of patients with dual disorders have an increasingly difficult task. In many areas, patients with dual disorders may not be recognized as a priority group for funding.No specific monies are set aside for patients with dual disorders under the block grants. The amount of funds that the Federal Government allocates to States for the AOD and mental health block grant programs changes from year to year and often includes mandated set-asides for specific groups (for example, needle users, women, etc.). Set-asides tend to be different for mental health and AOD abuse treatment and limit the amount available for special groups not specifically targeted.

States often do not take advantage of Federal monies that can be used for patients with dual disorders. It is difficult to identify Federal grants that can be used for dual disorders, since grants and announcements are scattered across many agencies such as the Substance Abuse and Mental Health Services Administration (SAMHSA), CSAT, the Center for Substance Abuse Prevention (CSAP), the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute of Mental Health (NIMH), and theCenter for Mental Health Services (CMHS), to name a few.

Current reimbursement practices inhibit integration of services and effective treatment, and there are several problems related to reimbursement from both public and private third-party payers. These problems include the following:

• There are separate monies for AOD abuse and mental health treatment.
• The span of coverage limits the types of services that can be provided in each setting.
• Few standards exist that define minimum benefits for either AOD abuse or mental health services.
• Depending on the type of treatment program in which patients participate, the separation of AOD abuse services and mental health services often drives the: 1) primary diagnosis, 2) type of treatment, 3) level of treatment, and 4) level of reimbursement.This causes competition for benefits rather than cooperation.
• Benefit funding levels vary dramatically.

Solutions

Problems

Only limited treatment and research data are available, and those that are available are not in a standardized format. Existing data also tend to be general and not useful to local planners for developing a continuum of care. Data collection systems are mandated to be separate from each other.It is difficult to gather prevalence data on patients with dual disorders because many of them interact with several treatment agencies or systems, while others do not interact with any.

There are systemic disincentives to gathering data on patients with dual disorders. For example, Medicaid may cover a patient who makes a suicide attempt as a result of major depression, but may not cover a patient who makes a drug-induced suicide attempt.

Solutions

At least on the State level, common identifiers in data collection should exist for both AOD abuse and mental health treatment systems. Research should be in a form that allows for evaluation of cost-effectiveness and outcome.Outcomes should be measured across several categories encompassing biopsychosocial issues. Examples might be 1) severity of AOD and psychiatric symptomatology, 2) housing, 3) service involvement and utilization, and 4) vocational involvement. Collaboration with local colleges and universities to conduct such research should be encouraged.

State planning bodies should encourage or require local needs and resource assessment and data collection. Local planners should collect data from various systems, examining and comparing data from different groups, programs, and locations. The State could gather all the data and compile them for use in improved planning and in evaluating outcomes.

Confidentiality laws must protect the patient, but also must allow for inclusion of anonymous case number data in pools to promote better assessment and treatment outcome studies.

There should be aggressive efforts to examine cost-effectiveness and outcomes of specific models of treatment services for patients with dual disorders.These research efforts can be incorporated into State and local initiatives, perhaps involving local colleges and universities.

Problems

Linkages in the development of programs for treating patients with dual disorders are impeded by several factors:

• Rigid models, resistance to changing programs, and turf battles
• Regulations and reimbursement rules
• Clinical assumptions about dual disorders
• Program development driven byreimbursement rules rather than by patients' needs
• Limited knowledge about what is effective; absence of outcome research for program models
• Absence of good processes for disseminating information about existing programs throughout the country
• Lack of standards for comprehensive dual disorders programs
• Lack of incentives for good program development on the State and local levels
• Absence of State licensing criteria specific to dual disorders
• Lack of appropriately trained staff and other resources
• Lack of ownership. Dual disorder treatment systems are not "owned" by the AOD abuse or mental health treatment systems.Therefore, development of dual disorder treatment programs is not a priority in either system.

Solutions

• Provide financial incentives for integrated dual disorder treatment programs.
• Provide grants for model program development.
• Identify State and county dual disorder experts.
• Publish a State bulletin to facilitate information exchange.
• Encourage research on existing programs from both AOD abuse and mental health fields by collaborative grants between States and universities.
• Determine how existing services can be adapted (such as with special tracks or staff training to serve the dually diagnosed population) and help define which services need to be developed and which are special and unique to groups (for example, detoxification, longer-term residential programs, halfway houses). For example, the State of New Jersey issued guidelines for a continuum of care that describe how to adapt existing AOD abuse and mental health services and what services need to be specialized to care for dual disorder patients. The guidelines serve as a blueprint for systems integration.
• Publish a State glossary of terms to encourage communication across systems.
• Make sure programs have integrated expertise from both AOD abuse and mental health treatment fields through a joint review process for RFPs as well as joint ongoing monitoring processes.
• Review programs for gender and cultural competency.
• Establish a consumer feedback process to modify programs.
• Encourage the involvement of providers, patients, and their families in educating the public on the needs of dual disorder patients and advocating for resources.

Problems

The screening process amplifies the tendency to look for a single diagnosis.Staff in single-focus screening services are not trained to assess patients for dual disorders.

There is no "gold standard" instrument to diagnose dual disorders. Some of the instruments that are used often yield false positive results.

Screeners are not adequately trained to make effective referrals across systems, which can result in denial of treatment services.

Screening for dual disorders may take longer than screening for a single disorder. For example, psychiatric symptoms can appear or disappear as the AOD-induced symptoms clear.

Solutions

• State policies should lengthen the time frames in which screening and assessments are done for patients thought to have dual disorders. State policies should recognize that screening and assessment are ongoing processes.
• The Federal Government should encourage research to develop standardized screening and assessment tools for dual disorders.These tools should be appropriate for people with severe and moderate AOD and psychiatric problems.
• There should be systems-wide training of gatekeepers on the proper way to screen for dual disorders and on effective ways to make referrals.
• There should be widespread encouragement of the multidisciplinary approach through joint staffing of screening centers or on-call backup support.

Problems

There frequently is no single person or agency responsible for following up on referrals and ensuring that patients are linked to treatment and that services are coordinated. People with dual disorders need others to help them obtain the services that they require, which are often fragmented.

The Public Health Service Act requires that State mental health agencies that receive Federal funds provide case management services to patients with severe mental illness. However, a comparable requirement is not built into the Federal mandate for AOD abuse treatment services. AOD abuse treatment agencies usually do not have enough social service staff to handle the case management functions of linkage or followup for many dual disorder patients.

Solutions

• States and agencies need to define criteria for patients who need and do not need case management. Case management should be targeted to those who need it, while less severely ill persons should receive other services.
• Develop multidisciplinary teams with expertise in dual disorders within AOD and mental health treatment settings. Also, encourage the use of peer counselors to help engage patients with dual disorders into appropriate treatment.
• Encourage a continuum of case management, defining who should get what level of case management. Levels may range from treatment plan coordination while the patient is in treatment to coordinating services within the community (such as Social Security Income [SSI] and housing). Assertive mobile outreach teams can encourage out-of-treatment individuals to become engaged in treatment. These efforts can help potential patients who are reluctant to participate in treatment or who are unable to get to treatment.
• States should help increase the case management function within the AOD abuse treatment field. Ways to develop collaboration by including AOD treatment experts in a mental health facility and in outreach operations should be found.

Problems

All too often, treatment staff are knowledgeable about either mental health or AOD treatment. They lack thorough training and education about dual disorder patients.

There is often insufficient staff time available for the level of case management required for dual disorder patients.

Staff selection is often driven more by clinicians' academic degree and their ability to provide reimbursable services than by clinicians' expertise in dual disorders.

Solutions

• Standards for staffing dual disorders programs should be developed. These standards should include expertise in meeting the emotional, social, psychological, biological, vocational, and recreational needs of the patient.
• A certification process should be established for certifying clinicians who have expertise in treating dual disorders. Third-party payers should be encouraged to reimburse based on clinicians' knowledge, competence, and expertise rather than on academic degree.

Problems

Clinicians in AOD abuse treatment and mental health treatment usually are not trained in the other discipline. The availability of staff trained in both fields is limited. Agencies frequently lack the resources to recruit and retain staff who have sufficient education and experience. There is both a shortage of qualified staff and an inability to financially compensate qualified staff for their specialized abilities.

The diagnosis and treatment of dual disorders are not generally understood by staff, administrators, and legislators, let alone the general public.Agency directors and supervisors often assign whom they believe to be the most appropriate staff member to work with dual disorder patients without a clear idea of the knowledge and skills required.

Professionals in AOD abuse and mental health treatment have accumulated biases against the other discipline, as well as negative stereotypes of both patients and staff.

There are no structured incentives for individuals or programs to develop or take part in training, such as pay differentials and career opportunities specific to dual disorders. Opportunities and incentives for cross-training are lacking.

Consumers are not adequately involved in the training process.

Relatively few academic programs involve training or research in this field.

Solutions

Cross-training is one of the most effective tools administrators have for bridging gaps between clinicians and services from different fields. Training programs that provide knowledge about local networking can greatly improve linkages for patients with dual disorders.

Problems

A large proportion of patients with dual disorders require social services.The scope of social services is extremely broad, encompassing public and private multisystems.

Federally mandated income support programs are notoriously complex, each with its own set of regulations. Some, such as the Social Security Income (SSI) maintenance program, are administered by the Federal Government, while others are administered by the State and vary from State to State.

Income support programs include SSI, Medicaid,Medicare, welfare, Aid to Families With Dependent Children (AFDC), and food stamps.

Regulations for each program are often not understood by professionals and others who provide services to potential recipients. This makes it even more difficult for the potential recipient to get and retain benefits.

Some programs, such as SSI, require proof of a permanent and total disability. Mental health problems often do not neatly fit into categories, making it difficult to obtain this support.

Income support programs for single individuals have been cut drastically in recent years.

Applications for these income support programs are often taken at a site other than where either mental health or AOD services are provided for the patient.

The complexity of the application and appeal process adds to the stress of a person with a dual disorder.

Overburdened staff who are processing income support applications often do not understand dual disorders.

Federally mandated services for children, youth, and families include services that fall under the child welfare system (for example, child protective services and foster care placement).

Child welfare system staff are overburdened and understaffed. A large percentage of caseloads involve family AOD use problems.

Most child welfare staff are not trained in recognizing or treating dual disorder problems. Mental health and AOD abuse staff are not trained in child welfare. There is a lack of knowledge of each other's systems and resources.

Other social service programs serve a wide range of special needs populations, including the homeless and victims of domestic violence or sexual abuse, who require a broad array of support services. Although many users of these services have mental health and AOD abuse problems, these services are often not available on site. Social service staff often lack knowledge of how to refer people with such problems into these systems.

Solutions

• Train SSI maintenance staff about patients with dual disorders.
• Train AOD abuse and mental health staff in a range of social service areas, including income support, child welfare, and special populations.
• Encourage an on-site application process for income support programs at AOD abuse and mental health treatment facilities. Mental healthand AOD abuse treatment programs can request training and support from Federal, State, or local administrators of various income support programs.
• Develop mobile outreach approaches to assist patients with dual disorders in gaining access to income support programs and other needed social service programs.
• Encourage an ongoing exchange among policy-level staff of AOD abuse, mental health, and Social Security agencies on Federal, State, and local levels.
• Encourage a designated policy-level social services staff to create and maintain links with AOD abuse and mental health treatment systems.
• Allocate sufficient social service staff time to assist patients who need a range of supports and services.

Problems

The medical system is vast, covering a wide range of public and private programs including primary, secondary, and tertiary care.

Public primary care clinics are often overburdened, understaffed, and underfinanced. They are often oriented to treating presenting physical problems, and staff may not be trained in screening for either AOD abuse or mental health problems. The same problems often exist in nonprofit primary care facilities. Staff are often not knowledgeable about how and where to refer patients.

Historically, physicians have not received any education about AOD treatment and little education about mental health problems in medical school. Primary care physicians are often unaware of the signs and symptoms of AOD use disorders, and may have only a basic understanding of a few psychiatric problems such as depression and anxiety. For example, persons who experience physical trauma, such as burn injuries or falls, often have AOD use disorders. Yet, when presented with injured patients, primary care physicians may not screen for AOD use disorders.

At hospital discharge, personnel often have difficulty dealing with AOD abuse and mental health concerns. Patients are sometimes discharged inappropriately with inadequate discharge planning and linkage with aftercare services.

Staff in mental health and AOD abuse treatment systems often do not know how to gain access tomedical systems and therefore are ineffective in providing information and ongoing education.

Solutions

• AOD abuse and mental health staff should take the initiative to conduct t