Program Initiatives for Dually-Diagnosed at Harlem Valley Psychiatric Center. Dual Diagnosis - Co-occurring Disorders.

When John is not smoking marijuana, things seem okay. But when he starts, then the voices and paranoia start. He has a history of inpatient treatment at Harlem Valley Psychiatric Center which resulted from his delusions, paranoia, and violent outbursts. When he was discharged, his family did not want him back. Now he is successfully functioning in the community and attending a special treatment program for mentally ill persons with a concomitant problem of substance or alcohol abuse. "My group has taught me how not to be lonely and how to occupy my time. Even after I spilled my guts out, nobody here looked down on me."

Susan is a young anorexic girl who abused drugs and also had a drinking problem since she was 12. However, before she joined the special treatment group, no one know of her "secret" drinking problem. She saw something different going on in this group in the psychiatric center. Films were being shown. Speakers were coming in. She asked to join the group. Because of the special tone of acceptance and support she revealed her alcoholism secret. Now she is in a community day treatment program and group and has her alcohol and substance abuse problem under control.

Jim was part of the hippie culture in the '60s and was hospitalized all across the country. His abuse of drugs would activate psychosis which led to the hospitalizations. He has been in a number of substance abuse treatment programs but he calls the day treatment group at Harlem Valley "reliable." "In other programs they were like soldiers holding you hostage even to the point of harassment. Here people in the group are concerned about you and the treatment is not abusive."

These three cases illustrate a treatment approach in the Harlem Valley Psychiatric Center and its Community Services Areas which appear to employ effective strategies for treating very difficult patients: patients who are mentally ill with concomitant alcohol and/or substance abuse problems.

About two years ago (1984), (Kathleen) Sciacca began to focus on this problem at a grass roots level. Ms. Sciacca, who has played a key role in developing the treatment model for these dually diagnosed clients, remarked, "There was no clear treatment model directly applicable to the dually diagnosed client population with a primary chronic mental illness, and an alcohol or substance abuse problem. We had to develop a treatment model that continually adapted to the needs of this special population, and that featured a non-confrontational approach."

"We had to face the issue not merely of patient denial of these problems," says Sciacca, "but also staff denial - either that these problems existed or that they were possible to treat. Many staff, at first, couldn't face the realities of patient's continuing to drink or take drugs when they had counselled them to stop."

"We began to emphasize the similarities and differences in treating dually diagnosed patients and those patients without mental illness who had to cope with a single addiction."

Similarities, she points out, between dually diagnosed patients and patients without mental illness who have a single addiction include:

1. Use of a substance results in dependency so that the person becomes controlled by the substance.
2. Denial is an integral part of the disease: the patient can't perceive the scope of the problem.
3. The individual experiences guilt and becomes defensive: "I could stop if I wanted to."
4. The patient becomes physically addicted.
5. Need for support and meaningful relationships to stop.

Differences with patients who are mentally ill:

1. Patients are taking prescribed medications which do not mix and often have ill effects when they interact with illicit substances.
2. Abusing or simply using drugs and/or alcohol may result in activating psychiatric symptoms.
3. Continual use of the substance may result in decompensation and re-hospitalization.
4. Many patients are uncomfortable when attending substance/alcohol abuse programs and are often rejected from these because of their psychiatric illness.

Ms. Sciacca highlights other important points in treating the dual diagnosed patients. "The approach has to be non-confrontational because of the fragility of these illnesses. Clients have to proceed at their own pace. We can't use a moral model constantly viewing and accusing the patients of lying when they deny the scope of their problems. The underlying attitude (and reality) is that they are ill. Through education we have to try to teach the clients about the issues that are affecting them. We try to use practical education media such as videotapes, literature, speakers who bring the latest results of research on what alcohol and drugs can do to them and how to cope and rehabilitate. We use this approach with our staff leaders and therapists too. This approach to leadership of these patients has to be, in part, exploratory. The leaders come to groups learning with and from the research and the groups. Clinicians have to convey to the patients they realize how hard it is to stop. They have to give the patients credit for any accomplishment. That's where the focus has to be - on any inch of progress, how well the patient is doing. The leaders have to set the tone of non-confrontation and acceptance for the groups to be effective in peer support and encouragement."

Ms. Sciacca has developed a valuable assessment questionnaire for substance using clients, a questionnaire which assesses a number of client problem areas and includes recommendations and objectives that serve as a treatment guide for staff.

There are three recognized phases in the treatment process: 1) a phase of extreme denial, resistance, and distrust by the patient; 2) still denial but more interest in learning about the issues and some growth in understanding their own issues and situations; and 3) patients work on abstaining in a open and candid manner. "New patients are entering the groups at different phases," notes Ms. Sciacca. "The patients who are recovering serve as excellent support and role models for those strongly addicted or denying their addictions."

At this point there are obvious documented successes:

• Patients were better able to discuss their substance use problems more openly with staff and peers.
• Patients gained education, patient information, awareness, and insights into alcohol/substance abuse.
• Patients remained out of the hospital entirely or for longer periods of time.
• Patients were able to give and receive support.
• Patients remained abstinent from alcohol/substance abuse.

This program, at first appearance, seems to meet recommendations in the Commission on Quality of Care for the Mentally Disabled report on this topic (1986):

• OMH is the agency on the local level responsible and accountable for coordinating and delivering appropriate treatment.
• It is a particular model to address the psychiatric and chemical abuse treatment needs of mentally ill patients.
• It has a well-coordinated interdisciplinary training program for clinical staff.
• It required no new funds or reimbursement policies to put the program in place. (However, administrators point out that at the facility level it was necessary to carve out 1.5 staff items from already stretched staff resources to conduct the program.)
• It identified and clarified particular treatment needs for this population.