The following report was generated in response to Senate Joint Resolution 8 which charged the Department of Mental Health and Mental Retardation with the responsibility of studying the dual diagnosis client, estimating the number of these clients, and recommending ways of assuring that dual diagnosis clients receive the services they need. Because existing literature provided little insight into the problems of the dually diagnosed client, a major exploratory study was conducted to map the domain of dual diagnosis. Using a working definition designed solely for sample selection (and not for diagnostic or treatment planning purposes), the study

1. Identified all dually diagnosed individuals in the department's institutions (N = 788; 47 .6% from psychiatric facilities, 52.4% from training centers) and a significant portion of the estimated 4200 dually diagnosed individuals in the community (N.B., the actual number probably falls within the range of 3400 and 5000) for study

2. Performed two functional assessments on each of the 1371 identified dually diagnosed individuals.

3. Analyzed the results to identify dimensions underlying dual diagnosis.

Individuals identified as dually diagnosed were seen to display a wide variety of adaptive and maladaptive behaviors. The majority of these behaviors, though representative of an equally broad range of diagnostic groupings and etiologies, were shown to have a common underlying dimension: deficits in impulse control. It should be noted that a small percentage of cases do, however, show a combination of mental retardation and a clear cut psychiatric disorder. In such cases, mentally retarded individuals (i.e., developmentally-based retardation) show acute psychotic behavior.

A crucial finding regarding this deficit in impulse control (and its concomitant maladaptive behaviors) is that, looking across the entire population of mentally retarded individuals (i.e., dually diagnosed individuals and all other retarded persons), there is a continuum in this deficit that can be modeled as a statistically normal distribution (see Figure 3 in the text). With deficits in impulse control a cardinal feature of mental retardation, most retarded individuals show some degree of impulse control-related problems. For the majority of all retarded individuals, these deficits have resulted in few if any behavior management problems; these individuals can be seen in Area 1 of Figure 3. Beyond a certain level, however, these deficits in impulse control result in a management problem for service providers; these individuals come to be labeled as dual diagnosis (i.e., Areas 2 and 3 in Figure 3). Within the dual diagnosis subpopulation there is also great variability in the magnitude of the impulse control deficit and attendant maladaptive behavior. For most of these individuals (i.e., Area 2), a significant deficit has required an increased level of behavior management, the technology of which reportedly needs to be developed in our service delivery system. For a very small percentage of cases (i.e., Area 3), behaviors related to this impulse control deficit are completely out of control. Such individuals could not be maintained in routine community and institutional programs without stabilization.

With the study completed, a meeting of the Assistant Commissioners for Mental Health Services, Mental Retardation Services, and Technical Services was convened to bring together the administrative perspectives needed to address the problems of dually diagnosed clients. At this time, the three Assistant Commissioners unanimously offer the following recommendations:

1. Rather than using the label dual diagnosis, service providers should deal with individuals in terms of their specific behaviors. The label of dual diagnosis provides too little information regarding treatment needs, whereas a more individualized behavior assessment can focus on the appropriate strategies for providing service.

2. Service providers (i.e., mental health, mental retardation, community, institution) must acknowledge that 1) routine rnanagement of behaviors based in impulse control deficits and 2) training/habilitation are simply part of the service array expected of them.

3. It would appear that the behavior of some retarded individuals occasionally will become so out of control that intensive stabilization services, beyond those typically offered by a community program or training center, are needed (i.e., Area 3 of Figure 3, in the text). If service providers are to face up to their responsibility to serve, some support systems must be made available to assist them during these difficult periods.

Given the small numbers of such cases in individual agencies/facilities and the current economically constrained climate, extensive development (i.e., within individual agencies) of intensive stabilization services may be impractical. Rather, what is indicated is that the department take the lead by developing institutional capability for intensive stabilization services. Two settings are envisioned for such services:

A. The Social Skills Center at Lynchburg Training School and Hospital, and

B. Specialized stabilization units to be developed within the larger psychiatric facilities.

Whereas the structure for the SSC program is already in place, programs in the psychiatric facilities would have to be developed. It is therefore proposed that a pilot program be created in one facility at this time. With refinement of the program during a trial period of operation, other units can be developed later. The issue of how to admit these individuals without violating their rights must, however, be explored before the implementation of any such program.

While responsibility for these stabilization services has been placed on the institutions, communities should not be penalized or discouraged from starting discrete (i.e., freestanding or isolated) stabilization programs if it is felt to be a priority and need can be demonstrated.

4. Existing programs must develop their own internal capabilities to provide service and routine behavior management to individuals whose behavior problems relating to impulse control are significant, but not out of control.

These are the individuals in Area 2 of Figure 3. They show behavior problems, but not so severe as to require the stabilization services identified in Recommendation 3.

Programs need to access the combined behavior management/habilitation technology which facilitates working with these clients. A listing or library of programmatic resources should be maintained by the Department of Mental Health and Mental Retardation and available through community coordinators and/or a representative from the institutional services division.

The development of behavior management programming should be reinforced by bolstering community program certification standards regarding behavior management.

5. No beds in training centers that have been certified under ICF /MR regulations should be "decertified". Limitations on the use of behavior modification programs, physical restraint, and psychotropic medication, as specified in ICF/MR regulations are not felt to be so restrictive as to indicate the decertifying of some beds.

6. Mentally retarded individuals currently in psychiatric institutions who require no further psychiatric services should be identified as a priority for discharge or, as necessary, for transfer to a training center. Oirectors from psychiatric institutions should be charged with reviewing their rolls and developing a plan to move such individuals from their facilities. Such plans should include:

A. A list of individuals suitable for discharge to the community and their aftercare needs.

B. A list of individuals to be considered for transfer to a training center.

C. A plan for serving those mentally retarded individuals awaiting transfer to a training center until such transfer is enacted.

D. A timetable for completing discharge or transfer of these patients. Retarded individuals requiring the services available at a training center should be established as a priority for beds which open up in the training centers. An appropriate formula for accessing the beds should be negotiated with each training center director based on turnover from the facility and community demand for beds.

7. In conjunction with the Departments of Special Education, Social Services, and Health, community services boards should implement prevention programming aimed at the impulse control-related behaviors which have led to the dual diagnosis label. Development of problem-solving/behavior alternative skills, and coping abilities might be incorporated into the spectrum of community mental retardation services. Drop-in centers and community support systems could be developed. Such programming should acknowledge the psychological needs (as opposed to the behavioral problems) of the mentally retarded individual living in the community.

8. Those individuals who show significant behavior problems relating to impulse control should be a priority for case management.

9. A task force composed of institution directors, executive directors from community services boards, professional service staff, central office administration, members of the original task force, and other concerned parties should be convened. This task force would be charged with preparing for the Commissioner of the Department of Mental Health and Mental Retardation an implementation plan for the preceding recommendations.