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May 2009 – Tips & Topics

Volume 7, No.2
May 2009

In this issue
– Until Next Time

Welcome to the many new subscribers who joined us this month for your first edition of TIPS and TOPICS. Thanks to all who have expressed appreciation and sent along nice feedback.


Here is a glossary of terms and acronyms in the paragraphs to follow:

  • Addiction-Only Services (AOS)
  • Co-Occurring Disorders -mental health and substance related disorders (COD)
  • Dual Diagnosis Capable (DDC)
  • Dual Diagnosis Capability in Addiction Treatment Index (DDCAT)
  • Dual Diagnosis Capability in Addiction Treatment for Mental Health (DDCAT-MH)
  • Dual Diagnosis Enhanced (DDE)
  • Mental Health-Only Services (MHO)
  • The American Society of Addiction Medicine Patient Placement Criteria, Second Edition, Revised (ASAM PPC-2R)

Many states, counties and agencies are striving to be Dual Diagnosis or Co-Occurring Capable. The ASAM PPC-2R describes three types of programs for people with COD; these program types can be established at any level of care.

In the June 2006 edition of TIPS and TOPICS, I outlined some characteristics of Addiction-Only Services (AOS) and adapted AOS to describe Mental Health-Only Services (MHO); Dual Diagnosis Capable (DDC) Programs; and Dual Diagnosis Enhanced (DDE) Programs.


  • How Dual Diagnosis Capable are you or your program? The DDCAT and DDCAT-MH may help you identify this.

While the ASAM-PPC-2R has provided brief descriptions of services for people with co-occurring disorders, it has not provided operational definitions or pragmatic ways to assess COD program services.

The DDCAT Index
This is a fidelity instrument for evaluating addiction treatment program services for persons with COD. The DDCAT developed assessment items and objective measures to help determine the dual diagnosis capability of addiction treatment services for COD.

This is an edited version of the DDCAT for use in mental health service programs. Although the DDCAT had its origins in the addiction field, the domains and elements of the DDCAT Index are also applicable to mental health programs.

The 7 Domains of DDCAT and DDCAT-MH

The DDCAT evaluates 35 program elements that are subdivided into 7 domains; these are components of an overall service structure for any given addiction or mental health treatment program.

–> Program Structure: focuses on general organizational factors which foster or inhibit the development of Co-Occurring Disorder (COD) treatment

e.g., mission statement; certification & licensure; coordination and collaboration with substance related services; financial incentives

–> Program Milieu: focuses on the culture of program and whether the staff and physical environment of the program are receptive and welcoming to persons with COD.

e.g., routine expectation of and welcome to treatment for both disorders; literature and patient educational materials

–> Clinical Process – Assessment: examines whether specific clinical activities achieve specific benchmarks for COD assessment.

e.g., routine screening for substance-related symptoms and assessment for positive screening results; substance use and mental health diagnoses made and documented; substance use and mental health history reflected in medical record; service-matching based on substance related symptom acuity: low, moderate, high; service matching based on severity of the persistence of disability: low, moderate, high; stage-wise treatment initial

–> Clinical Process – Treatment: examines whether specific clinical activities achieve specific benchmarks for COD treatment.

e.g., treatment plan; assess and monitor interactive courses of both disorders; procedures for substance related emergencies and crisis management; stage-wise treatment ongoing; policies and procedures for medication evaluation, management, monitoring, and compliance; specialized interventions with substance related content; education about substance related disorder and its treatment, and interaction with mental health disorders and its treatment; family education and support; specialized interventions to facilitate use of COD self-help group; peer recovery supports for patients

–> Continuity of Care: examines the long-term treatment issues and external supportive care issues commonly associated with persons who have COD.

e.g., co-occurring disorders addressed in discharge planning process; capacity to maintain treatment continuity; focus on ongoing recovery issues for both disorders; facilitation of self-help support groups for COD is documented; sufficient supply and compliance plan for medications is documented

–> Staffing: examines staffing patterns and operations that support COD assessment and treatment

e.g., psychiatrist or other physician; onsite staff with substance abuse licensure; access to supervision or consultation for substance related disorders; supervision, case management or utilization review procedures emphasize and support COD treatment; peer/alumni supports are available with COD

–> Training: appropriateness of training and supports that facilitate the capacity of staff to treat persons with COD.

e.g., basic training in prevalence, common signs and symptoms, screening and assessment for substance related symptoms and disorders; staff is cross-trained in mental health and substance use disorders, including pharmacotherapies.

References and Resources

1. Mee-Lee D, Shulman GD, Fishman M, Gastfriend DR, and Griffith JH, eds. (2001). ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition-Revised (ASAM PPC-2R). Chevy Chase, MD: American Society of Addiction Medicine, Inc.

See Pages 7-11 for more detail on Co-Occurring Disorders.

2. “The Dual Diagnosis Capability in Addiction Treatment (DDCAT) Index:
Mark P. McGovern 1, Julienne Giard 2, Jessica Brown 3, Joseph Comaty 3, Kirsten Riise 4

(1. Department of Psychiatry, Dartmouth Medical School, Lebanon, New Hampshire
2. Department of Mental Health and Addiction Services, State of Connecticut, Hartford, Connecticut
3. Department of Health and Hospitals, Office of Mental Health, State of Louisiana,
Baton Rouge, Louisiana
4. Department of Health and Hospitals, Office of Addictive Disorders, State of Louisiana, Baton Rouge, Louisiana)

3. “The Dual Diagnosis Capability in Addiction Treatment for Use in Mental Health Programs (DDCAT-MH) Index: An Introductory Manual (Version 2.4)”
Jessica Brown, Joseph Comaty, Mark P. McGovern, & Kirsten Riise

For information pertaining to the DDCAT Index, implementation, training or research with the DDCAT please contact: Dr. Mark McGovern, Department of Psychiatry, Dartmouth Medical School, 2 Whipple Place, Suite 202, Lebanon, NH 03766. (603) 448-0263 or

For information pertaining to the DDCAT administration, scoring and interpretation manual, please contact: Dr. Jessica Brown, Bureau of Applied Research and Program Evaluation, Office of Mental Health, 1885 Wooddale Blvd., Room 925, Baton Rouge, LA 70806. (225) 922-3244.


At a recent workshop, I used a clinical vignette of a client, Stephen. Participants were asked to decide whether Stephen needed DDC or DDE services.


  • How would you decide whether a client needs DDC or DDE services?

A brief reminder:

DDC Programs: Dual Diagnosis Capable
These programs routinely accept individuals with co occurring mental and substance related disorders. They can meet such clients’ needs so long as the co-occurring disorder is sufficiently stabilized. Also the individual must be capable of independent functioning to such a degree that the co occurring disorder does not interfere with participation in treatment.

DDE Programs: Dual Diagnosis Enhanced
These programs can accommodate persons with COD where both disorders are unstable. As a result, both disorders need active, integrated addiction and mental health treatment by cross-trained COD competent clinicians.

Here’s Stephen’s case. See what you think.

Stephen is 51 years old and is accompanied by his wife. He wants help, but is depressed. During his intake interview for this, his second Driving Under the Influence (DUI) arrest, he looks disconsolate and he speaks in a monotone as he wonders if his wife will leave him. His alcohol use has resulted in alienation from his children, guilt feelings and his job may now be threatened, as he has been warned by his supervisor about his poor attendance and performance. Most of his friends drink, but none of them think he is an alcoholic.

He has not had any previous addiction treatment other than DUI classes after his first DUI four years ago. He attended Alcoholics Anonymous (AA) for six months on and off and did have a sponsor, but felt more and more that he wasn’t as bad as others at AA and gradually stopped going.

Stephen has been alcohol-free for three weeks. He has used cocaine (snorting) about three times per month over the past four years, but stopped two months ago. He has had no legal or financial problems related to cocaine. Stephen has continued on diazepam (Valium) 5 mg. four times a day (qid) which he has taken for five years to relax him because of mild hypertension. He has no other chronic physical problems but has lost 10 pounds weight over the past month and has been sleeping poorly. He wishes he could sleep and get away from all his problems but denies any organized suicidal plans and says he wants help.

Placement Decision and Discussion

Most participants voted to place Stephen in an addiction DDC service for the following reasons:

–> He clearly has an addiction (alcohol, cocaine) and depression problem. However, his depression could well be related to post-acute withdrawal, untreated addiction in that he is “dry” but not sober nor growing in recovery.

–> While the depression, weight loss, wishes to sleep and get away from his problems all need further evaluation along with his use of Valium, Stephen is not actively suicidal needing close checks and tight psychiatric monitoring.

–> An addiction DDC service could collaborate with mental health on assessing Stephen’s depression; and work with his primary care physician to understand whether Stephen actually has hypertension and what other treatment instead of Valium is warranted.

–> If his depression worsened then, DDE may be necessary if, for example, Stephen became more specifically suicidal or deeply depressed.

I agreed with this line of reasoning for placement in a DDC service.

A Dissenting Voice

A few days later, a workshop participant who had chosen Addiction Only Services (AOS) wrote me, not convinced that we were correct:

“I looked at the situation about Stephen that you presented to us again and want to let you look at this case. At no time did Stephen admit he was depressed (which is a big thing if he admits it). The writer is the only one who mentioned that Stephen is depressed (stated like a nonchalant statement that didn’t matter). He just looked “disconsolate and spoke in a monotone voice.” All of our clients speak the same way whether they are depressed or not wanting to admit everything.

This is why I chose an AOS service because there wasn’t enough information yet (it didn’t seem like a real case or real interview). I would like to see a SASSI done on him and also other testing before I make a decision to place him a DDC level (more evidence). The sentence stated that, “He wants help, but is depressed.”

If Stephen hadn’t stated he was depressed during the interview, he may not admit depression on a Beck inventory. The situation seemed to be more like he was feeling sad and guilty because his wife was present (which lots of our client do) and about his job (I would feel guilty and sad also and speak in a monotone voice also if this happened to me). I would try to see how Stephen is without his wife present.

All clients say they haven’t used alcohol and drugs for a while but a good alcohol and drug test is the only way to check out the truth. Who knows he could have drunk the night before the interview (which many of them do). An addict will continue to use despite the consequences. They can lie just as well as telling you the truth. After the drug test came back then I would have a better picture on what the client needs. Then I would make a decision to bump him to a DDC level by taking a look at all of his information.”

A Counselor from Nevada

Here is my response

Thanks for your thoughtful discussion.

In a brief vignette like this, yes, you would explore all of the assessment questions and ideas you raise. The ASAM Criteria wants everyone to be at least in DDC and not just AOS. Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications, would definitely need further evaluation. You would not just assume that any depression (observed and/or stated by the client) is just addiction.

Even if your first thought is that the depression might just be part of his addiction, you would still need to assess carefully Dimension 3 issues. This is, in fact, what it means to be a DDC program. So functionally you would be doing DDC work when doing this evaluation. It may seem like semantics and hair-splitting, but there are some programs (AOS) and some clinicians (AOS) who would not explore the issues as you stated and therefore could miss a significant depression.

The Bottom Line

While the ASAM Criteria describe Addiction Only Services, there are no criteria to describe who should be in AOS. Why? We want all programs and clinicians to be at least DDC/Co-Occurring Capable. Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications should be assessed for all clients to rule in or rule out conditions which may need mental health services.

It would be OK to be an AOS program if none of your clients have any Dimension 3 issues! But that wouldn’t seem to be a very large population.


The budget deficit in California is much like every other state’s, only worse. The current deficit is $ 24 billion – that’s with a “b” not an “m”. Admittedly, California’s economy is the 8th largest in the world, but that deficit number still has lots of zeros. So there’s going to be much debate and conflict over how California (and the USA) is going to live within its means.

Whenever resources are tight, when competition for funding is fierce, when battles rage to win the hearts and minds of people about political, religious or social controversies, people of goodwill easily morph into people of ill will. Somehow name-calling, quotations out of context, half truths, and personal attacks are justified- under the righteous banner of correcting historical injustices or advancing the greater good.

So doctors who perform abortions are shot at in the name of promoting rights to life. Women berate and disrespect men with the same degree of viciousness as men oppress and disrespect women. In the behavioral health field every day, people of goodwill sacrifice to serve those afflicted with mental health and addiction problems. Even there, contentious conflicts arise in debates over the use of medication in addiction treatment; or the place of electroconvulsive therapy; or over working with the criminal justice system.

I have puzzled and marveled about people’s inhumanity to people for years, especially amongst people of goodwill. So it caught my eye as I was reading a report on President Obama’s address at Notre Dame University in the Sacramento Bee newspaper, May 18, 2009. The article reported on the President’s view: that the failure to use “fair-minded words” in the war of words over abortion overly inflames an important debate. He described an example in his own 2004 campaign website, which at one point referred to “right-wing ideologues who want to take away a women’s right to choose.”

When a doctor emailed him about the phrase, Obama ordered the phrase removed. “I didn’t change my underlying position, but I did tell my staff to change the words on my website. And I said a prayer that night that I might extend the same presumption of good faith to others that the doctor had extended to me. Because when we do that—that’s when we discover at least the possibility of common ground.”

So let the debates begin, but how about using “fair-minded words” and presumption of good faith in people of goodwill?


Last month we introduced you to “Helping People Change” – A Five Part Series Workshop – Live and Uncut”. Since then we have sold half of the first run.

One satisfied supervisor wrote me to say:

“I’ve already used one of the DVDs for a staff training! Very well received.”

Where can I read about the contents of the DVD set?

Read all the details at this website link.

Where do I buy?

Email us your order at and we’ll send you the Paypal information where you can pay with any major credit card.

Will you have a shopping cart soon?
Yes- a fully functional Shopping Cart on the website is still in process- Coming soon!

Until Next Time

Thanks for reading. See you in June.

DML Training & Consulting

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