The mentally ill substance abuser: challenges for the administrator.

Despite a high incidence of dual diagnosis among substance abusers and among the mentally ill, few programs provide the comprehensive services needed to address both problems simultaneously. Dual diagnosis presents a series of challenges for administrators: Which problem should be addressed first? Should admission criteria be altered to exclude such clients? Can more comprehensive services be offered within existing funding? Differences between the two domains of treatment exacerbate their inability to work together. Substance abuse programs often employ "recovering" individuals as treatment staff and offer relatively brief inpatient programs, often using confrontational approaches. Self-help groups are frequent adjuncts to treatment but disdain the use of prescribed medications. In contrast, programs for the chronic mentally ill usually do not employ former clients, have longer lengths of stay, include use of medications to alter behavior, and are more supportive and educational. Overcoming barriers to treatment must involve change in policies related to funding, staff training, admission criteria and differences in philosophy of treatment.