If men are from Mars and women from Venus, we probably need to operate from the premise that the Office of Mental Health and Substance Abuse Services (OMHSAS) and the Office of Mental Retardation (OMR) also hail from two different planets. While this is not a news flash for anyone, it is evident that the language, history and experiences of the two systems must be understood, addressed and acknowledged if we are to move forward and succeed in working together on behalf of persons with both a mental health and a mental retardation diagnosis. The concern, confusion and frustration expressed by professionals, consumers and families who are trying to bridge the two systems, may actually have more to do with the way terms are translated and interpreted. Positive Approaches is seen as a mental retardation system term, and is likely not understood by others as the "vehicle" used to stop restrictive and aversive practices in the mental retardation system.
Likewise, I suspect that it is not widely understood that in the world of OMHSAS, the Community Support Program, commonly referred to as CSP, is the vehicle for consumer and family involvement. CSP espouses equal representation among professionals, families and consumers. It attempts to do with one term what "Speaking for Ourselves" and "family centered / family focused" attempt to convey in the world of OMR.
To add a further element of confusion, the newest term gaining credence in OMHSAS is "recovery," which presumes individual growth, building on strengths, and looking at the individual in totality, rather than in terms of deficit or diagnosis. Recovery, in order to occur, changes the dynamics of traditional patient / staff roles and is compatible with person-centered planning.
The words that translate to both OMR and OMHSAS worlds and are used, or presumed, include choice, opportunity, flexibility, individualization, community, least restrictive, growth, homes, friends, gifts, hope, passion and many more. Currently in OMHSAS, particularly the area involving the state hospitals where many of the dually diagnosed people are likely to be when community resources have been unsuccessful or unavailable, there is a struggle going on with the practice and value of seclusion and restraint as a treatment intervention. At issue is the understanding and attitude change required by staff from all levels, to see the behavior as a response by the individual when something is not right. The approach has been for staff to manage patients and assure compliance, and if there is a problem, it's the patient's unwillingness to be responsible for his or her own behavior.
One of the major challenges facing state hospitals is preventing and/or reducing violence by patients toward each other or staff. Current literature suggests the display of violence by patients is due, in part, to the loss of control, the lack of choices, and a staff/patient relationship based on we/they. OMR has traveled this path in its effort to reduce the costs associated with the "million dollar" person; a person who is very costly to serve. They have developed some expertise in how to make attitudinal and system shifts with all the supports needed to be successful. It is a valuable resource that should be utilized.
OMHSAS, in particular the state hospitals, has psychiatrists who are currently working with people labeled as dually diagnosed. They do so because the people are committed, either voluntarily or involuntarily. Some of the psychiatrists have developed an expertise in working with this population and are quite good. This may not be widely known, and the perception by others is frequently quite the opposite. The second point to be made is that state hospitals are providers of inpatient psychiatric treatment. This is not always acknowledged or embraced by either system, for a variety of reasons. However, it is a place where the people are, and those who are dually diagnosed and are in state hospitals cannot leave until the community MH/MR system has developed a plan and has appropriate supports and services available. The expertise and assistance of both systems are necessary to adequately support them in the community. To do so, both systems must work together and send a message that these people are just as important as those with a single diagnosis. This area of two diagnoses is one of the few areas where two of something is worse than one.
There are a small number of people identified as dually diagnosed who are in state psychiatric hospitals across the state. Sleeves need to be rolled up, people from the state and the community must work together, and the ensuing result would be people leaving the hospitals with adequate supports in place, and perhaps, others even being diverted from admission.
We need to reaffirm basic values. If we look at the Everyday Lives document and the OMHSAS Mission Statement, the foundation and outcomes for both systems are not that different. This could be the news flash!
I submit the following recommendations:
1. Look at the principles, the actual words that drive "positive approaches," "recovery," "community support program." Focus on how the systems work together to operationalize the words for people who have dual diagnoses.
2. The dual diagnosis committees operating in the OMR regions should invite and encourage participation from the state hospitals. The state hospitals have people with dual diagnoses, psychiatrists who have developed expertise and staff who are capable and effective. State hospitals are, after all, treatment providers.
3. Case study presentations at regional and statewide committees should focus on community stabilization, admission prevention, or discharge facilitation. This brings the state, county, and providers to attention and affords the opportunity to bring about some tangible solutions.
4. The two systems could develop groups to support, encourage, and perhaps, even solve individual situations. Staff training, development, and system reform could focus on the values behind each term and system.
The Pennsylvania Journal on Positive Approaches is published by the Pennsylvania Office of Mental Retardation (OMR) Statewide Training Initiative through Temple University, Institute on Disabilities, University Affiliated Program and Contract Consultants, Inc., 105 Old York Road, New Cumberland, PA 17070. For subscription information, please contact Contract Consultants, Inc. at  774 - 5455. Copyright © 1997 OMR/CCI. All rights reserved.
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