NADD Bulletin Volume V Number 6 Article 1

Complete listing

Cooperation Between Mental Health and Mental Retardation/Developmental Disability Systems

Introduction

Ann R. Poindexter, M.D.: Many of the barriers we have had over the years in providing effective services for people with developmental disabilities and significant behavioral/psychiatric problems seem to result from bureaucratic problems at state or province level between the mental retardation and mental health systems. I know that these problems exist, but I also realize that they have been addressed in many parts of North America, as well as the rest of the world. Paul Kolstoe and I began work on developing a coordinated system in North Dakota about ten years ago-at that time we called this "Not mine-not yours-but ours." (When it's money it's "mine," when it's problems it's "yours," whatever happened to "ours?") For some months I've been involved in a dialogue with many people about these issues-the questions I've addressed to this (very) volunteer group are:

1.Has your state/province made any efforts to develop a cooperative system, or at least cooperative projects, between mental retardation/developmental disability and mental health systems to serve people who have significant psychiatric/behavioral problems as well as developmental disabilities?

2.If so, what?

3.How have these things worked out-successes, problems, etc.?

4.What seems to be the major barrier to working out issues of service delivery to this complex group of individuals?

5.Has your area developed any cooperative programs to specifically serve individuals with "dual diagnosis" who are involved in the criminal justice system?

6.What specific resources do you think your state/province needs to improve cooperative services to people with "dual diagnosis?"

(I also promised anonymity as to name and location for those respondents who requested this.)

Paul D. Kolstoe, Ph.D.: People just do not fit into neat categories. They fall between the cracks when we operate categorically. However, there is also not enough money to help everyone, so it is important to have guidelines on services to protect those with the most significant needs. Synergy is what we strive for in human services-making more out of what we have available and helping people develop natural systems in which to live, love, and learn-that is what we do. Synergy does not happen without flexibility, design and effort. When gears do not mesh there is the opposite of synergy-inefficiency at best and destructiveness at worst.

Mental health systems and mental retardation systems have several disconnects. They generally differ by operating speed, expectations/service standards, and a degree of theoretical asymmetry. Mental health strategies emphasize returning home as quickly as possible, whereas mental retardation services focus more on achieving stable home lives before making movements. With different expectations and service rules than mental health, the mental retardation system is often frustrated over definitions of stability, "mental illness" (versus "behavior"), and treatment goals. Finally, although we share the same theoretical and training backgrounds, the people we serve with mental retardation have a range of diagnostic complications for which the mental health system is "unprepared" because of: 1) the extremely low frequency of contact with the subpopulation (people with mental retardation); and 2) the inability of the diagnostic conceptualizations to cover the unique presentations.

Nevertheless, synergy is happening, and the dividends are worth celebrating. Through the efforts of NADD and the Mental Health Services Special Interest Group (SIG) of AAMR we are creating synergistic networks. My own North Dakota Developmental Center and State Hospital have merged into one administration with our joint vision: One Center-Two Specialized Facilities. We have already reallocated resources for more effective direct services, and are using our joint muscle to more effectively weather recent economic stresses. Clinically, we are "filling in gaps" by cutting through traditional agency boundaries to bring the full strength of the service systems together.

Nationally, reputations of our specialized professionals have developed into referrals, consultations, and greater cross-training opportunities. Organizations like NADD, AAMR, IASSID, and others provide a credible source for information and point of contact, and individual effort has forged reliable avenues of generally successful outcomes. This edition of the Bulletin highlights and celebrates such synergy and provides samples and examples.

Has your state/province made any efforts to develop a cooperative system, or at least cooperative projects, between mental retardation/developmental disability and mental health systems to serve people who have significant psychiatric/behavioral problems as well as developmental disabilities? If so, what?

Dr. A., eastern U.S. state: Yes. One occurred accidentally, when patients with psychiatric disorders and MR/DD accumulated because placements could not be found for them, and one state psychiatric hospital concentrated them in one unit. The second came about as a result of the first: the university-based consultation-liaison group to DDD, among others, was asked to propose a consultation and education service to the mental health crisis center, to find alternatives to hospitalization and shrink the inpatient population.

Any cooperative ventures seem to have worked poorly. Mental Health proved uninterested in the education component, and simply wanted us to act as a placement agency, or otherwise take the problem off their hands. DD, in turn, had no placements to offer in addition to what they already had, and our Crisis Service had no more access to these than the mental health system already had. The one area of success was prevention of hospitalization for persons who had sufficiently resilient family or other residential resources.

John Jacobson, Ph.D., New York: New York state has held a one-day teleconference jointly sponsored by OMRDD and OMH. Through the developmental disabilities council, there will be two training excellence centers developed-responses to a Request For Proposal are being reviewed, and local collaborative networks of providers are planned. NY state operates specialty dual diagnosis institutional units in several locations around the state. These serve to transition people from OMH institutions to community services, and are fairly effective in doing so. Most community providers are serving some portion of people with dual diagnosis, although back-up on clinical crisis or shifting needs tends to be supported by state staff locally. This should change with the establishment of the local networks which will include both MRDD and MH providers.

We have no evaluative data on these services specifically, although some relevant studies on services of professionals to these people have been published.

Martha Felker, Tennessee: I'm working in the upper Cumberland area of Tennessee as a behavior analyst. I'm training support staff at an east Tennessee provider agency in Dialectical Behavior Therapy techniques. Our state department has sunk quite a bit of money into getting this training up and running in Tennessee.

Ms. N. (parent), eastern state: We are going through hell with -(daughter) and the system. We are talking about apples and they are talking about oranges. I have contacted NAMI to try and get them to communicate with the DD higher ups because DD doesn't have a clue about mental illness.

Dan Peterson, Washington: In Seattle, our psychologists have been very proactive in offering training to MH service providers on the principles of Positive Behavior Support and how to develop such plans. The attendance from MH providers has been very good! The reasons that MH providers attend is because the state Division of Developmental Disabilities is contracting with local community mental health centers to provide enhanced in-home stabilization supports for individuals with behavaioral/MH challenges, and slots for crisis diversion beds. The application of resource has drawn positive attention to the service needs of individuals with dual diagnosis. My feeling is that when looking at systems development to address service needs for individuals with both mental health issues and developmental disabilities it is important to focus on why both systems would want to be invested in a genuine collaboration.

A second approach that has been largely successful is using cross-systems crisis plan meetings to further the quality of collaboration: (Editor's note: Enclosed was a link to that day's Seattle Post-Intelligencer, March 28, 2002 which described work done at the Crisis Triage Unit at the main trauma unit in the northwest, Harborview Hospital.) There are many ways to look at this effort, and of course one way is to look at the success that wrap-around services bring to efforts to reduce repeat hospitalizations and the costs associated with that. Wrap-around supports, it should be noted, also have costs, which weren't indicated in this article. Please note-though it is a small mention-that wrap-around meetings have been called to improve services for individuals with developmental disabilities. There is general benefit all around when individuals with developmental disabilities have access to competent mental health services when needed, and the lever for making this happen is to structure the flow of resources to create both incentives for collaboration, and disincentives for a territorial approach between service systems. Our experience is that service providers in the mental health system readily gain expertise in providing MH services for individuals with developmental disabilities once the resources and incentives are in place. There is always room for improvement of course.

Robin Friedlander, M.D., Vancouver, BC: (In our province we have had) development of mental health support teams by the ministry of social services, with an aim to support adults with developmental disability with mental illness in the community. This was set up with downsizing and planned closure of three large institutions in BC in the early 1990's. We've also had development of a tertiary care clinic for complex DD clients with mostly behavioral problems, which has survived 10 years. The teams are under the Ministry of Health (MOH). These programs do not seem really to be valued by some "antispecialisation" community advocates. Triage is through Ministry of Social Services (MSS), gate keepers for referral, but they lack the wherewithal to triage effectively. There have been no jointly funded/planned projects between MSS and MOH in the past ten years.

Stan Handmaker, M.D., New Mexico: The psychiatric consultant for the New Mexico Human Services Department (the state Medicaid agency) organized an Advisory Committee for Behavioral Health Needs for Individuals with DD/MI, including state agency personnel, behavioral health managed care organizations (BHOs), and clinicians and administrators of the University of New Mexico. The goal is "to develop networks to increase access to psychiatric services and to evaluate and recommend improvement in behavioral health services for individuals in the state of New Mexico with developmental disabilities/mental retardation, mental illness." The issues to be addressed were primarily access, training, and funding. Two subcommittees were formed-one to advise on clinical issues and one to advise on administrative issues. (This is an ongoing project-the "jury is still out" as to results.)

Betsey A. Benson, Ph.D., Ohio: The "Ohio Initiative" started in early 2000 with formation of a joint advisory committee to the two directors (ODMRDD, ODMH). Three subcommittees were formed, Best Practices, Training, and Intersystems. These groups met, with a number of outcomes. A Best Practices brochure was put together and a series of eight regional, one-day training sessions on dual diagnosis were finished in late 2001. As part of the regional trainings, local collaborative efforts were highlighted which were pulled together in a pamphlet and distributed to all attendees. There is a lot going on that people have just managed to make work on their own without state direction, but definitely with local leadership. Also as a part of the regional trainings, local work groups (generally county-based) were formed to develop goals to increase collaboration. More in-depth clinical training was also scheduled. (Editor's note: I've seen the Best Practices brochure mentioned above, and it looks quite good to me.)

Mike Myers (parent), Mississippi: I am convinced that Mississippi is doing it right! Having been a member of the Human Rights Committee at South Mississippi Regional Center for approximately ten years, I am totally convinced that persons with a dual diagnosis are receiving the best "state-of-the-art" treatment possible in the Mississippi Regional Centers. (No further details given.)

Max Mastellone, Ph.D., New Jersey: In other states it is not clear that the administrative split between government DD and MH agencies is the main factor that compromises collaboration. In -(another state) the services are together but administered at the county level. In New Jersey, DD and MH are separate divisions administered at the state level. Still, dually diagnosed clients fare better in NJ and even that has a long way to go. State contracts have supported the development of a couple of specialty groups to serve this population but they only reach a fraction of those in need. Most recently, DDD contracted with an agency to train and provide clinical consultation to the staff of state funded community mental health centers in support of their service to DD clients.

Dr. S., southeastern state: When I first arrived 14 years ago, I was informed that our Protection & Advocacy people had finally convinced the legislature that it was to the best interest of people with mental retardation to get them out of mental health facilities and into mental retardation centers. Our mental health system is less than ideal and basically offers medication as treatment (and some counseling that only the brightest of the brightest people with mental retardation might benefit from). This has worked out well for mental health, since they could thin their population by transferring any person with mental retardation. In my opinion, this has worked out well for people with mental retardation who have mental health problems.

Time after time, the mental health system has either ignored people with mental retardation or provided only quick, perfunctory, near-useless service. Their institutional settings only accept our people until they are no longer a clear danger to self or others. Often this means admission and discharge within a few days. The treatment recommendation is basically medication. When we have had discharge meetings with mental health facility staff, the atmosphere has almost always been icy, at least with their professional staff.

Neill Carson & Susan Morris, Toronto, Ontario: The last 15 years have seen significant change/development in services to individuals with a dual diagnosis in Ontario. These changes led to the eventual development in Toronto of a specialized tertiary Dual Diagnosis Program within the psychiatric hospital, now the Centre for Addiction and Mental Health (CAMH). The Dual Diagnosis Program at the Centre is a specialized program for individuals with a developmental disability and emotional/behavioural difficulties, their families, and care providers. There are four components to the program:

1.Community based consultations: Dual Diagnosis Resource Service, Toronto, is a partnership with the Griffin Centre which includes time-limited treatment services and in-home support, consultation, education, and system facilitation; and Dual Diagnosis Service-Peel Region, which is a partnership with the Housing and Support Program in Peel which includes assessment for access to low cost supported housing units, diagnosis, consultation, and system facilitation.

2.Inpatient unit-time-limited admission, 15 beds.

3.Day treatment-for inpatients and for up to 10 outpatients as an alternative to inpatient admission.

4.Education and training supports-case-based, and seminars/workshops.

The program has been developed based on an cross-sector collaborative and integrated service model, achieved through a variety of mechanisms:

"Integration of mental health and developmental perspectives within the staff team

"Service is focused in the community-admission to the inpatient unit is the last option, and, where at all possible, planned with discharge route identified before admission.

"Emphasis on joint/shared team work with community providers

"Comprehensive review of the client results in a biopsychosocial integrated consultation report

"Shared ownership with clients, families, and community providers from the point of referral through the use of time-limited contracts/agreements re who will be doing what

"Active partnerships established through formal written agreements with community programs in the developmental and mental health sectors which address access to crisis services, wrap-around approach to support the transition of long stay inpatients to boarding homes, access to specialized dual diagnosis case management, speech, language, and specialized psychiatric consultation, as well as with the Personality Disorders Program at CAMH

"Increasingly active academic and research role to enhance training and education opportunities

Donald K. Routh, Ph.D., Florida: It is only tangentially relevant, but there was recently (late 2001) a conference on research on mental health problems in people with mental retardation, sponsored by the NICHD, NIMH, NINDS, and the Kennedy Foundation, held in Rockville, Maryland. (Editor's note: Report from this conference can be accessed at http://www.ninds.nih.gov/news_and_events/Emotional_Behavioral_Health_2001.htm?format=printable.)

Phil Reiss, Israel: It gives me great pleasure to discover the occasional area of services in which we in Israel appear to be "ahead" of what's happening in the U.S.. It has long been the pattern here for people with mental retardation to receive mental health care, when needed, from the general mental health care services. There is a high degree of cooperation between mental health care professionals and staff members at residences and schools. Not all of the mental health care professionals are well-trained in behavioral approaches, but most of the people I've worked with are open to using them when there is a psychologist who'll take the lead.

Peter Bates, United Kingdom: Similarly, in the UK there is commonly a sharp divide between services, even where they are managed within the same agency. However, there are many chinks of light. I have been collecting examples of collaboration in the "minute particular." Over 50 agencies have found ways to improve relationships between their organizations, usually using just a single initiative as the bridge between their organizations. For example, in one place an advocacy group covers both services and therefore effectively serves people with overlapping needs. In another place, one or two facilities have set out to be "open access" to people carrying either or both labels. Elsewhere the staff teams have a joint meeting once a month and new staff are inducted by shadowing their "opposite number" for a day. In one place a mental health specialist and his learning disabilities (DD) colleague co-lead a "facing change" group for people from either service. Elsewhere the outreach workers in both agencies have committed to provide a worker to the other agency for the initial assessment appointment whenever this is requested. Yet another place has a "hard cases panel" that arbitrates on which service should coordinate care for the person with dual needs, and elsewhere the Population Needs Mapping explicitly counts people who have dual diagnosis. None of these examples are rocket science, but they appear to help in local areas, and move our people past the common initial complaint-"Our psychiatrist hates yours, so we can't do anything." (I'm sure that bizarre excuse is a problem unique to the UK!)

Brian Bonfardin, M.D., Tennessee: The state of Tennessee initially showed little cooperation with the mental health systems in northeast Tennessee. My experience was seeing the residents of institutions discharged into the area mental health systems where inexperienced professionals saw them and these professionals were given very little time to learn and treat. I have had the opportunity to help develop two programs in northeast Tennessee. The first I started in 1995 with Frontier Mental Health System where they gave me a case manager to follow about 80 clients in the community. The state was not involved in this program. Through a flexible attitude within the mental health system I was able to see people outside of the centers and given flexibility with billing and coverage. The program now includes two case managers and seems to work well. The Frontier system supports my training these case managers and now is asking me to train staff across their system. We get a lot of referrals from within the system and are now turning a lot of people away. It's still based on brief visits and a lot of e-mail and phone calls to put out emergencies. The state supports the program only through billing (TN Care), and has not involved their system much. The second program is a state funded grant through a Mental Health System in Knoxville, Helen Ross McNabb (HRM), to complete comprehensive psychiatric evaluations on Class Members from the DOJ investigation. This program is fully state funded and is overseen by state bureaucrats and HRM does most of the immediate oversight. We are relatively new, a couple of years old, and the HRM is still able to keep the bureaucracy at arms length. We are really doing some good with this program, I feel.

Dr. N., eastern state: No formal arrangements have been made. However, people with both mental illness and DD are served in state psychiatric hospitals because there is no where else that they can get any meaningful inpatient services. There is an out-patient clinic at one of the DD facilities which provides limited services for the MR/MI population in northern -(state). A new state-level committee has been formed to look into this issue. But, this was not prompted by the need to serve people with MR/MI. Rather this was prompted by DOJ investigations of state psychiatric hospitals where they found the MR/MI to be an ill-served or under-served population. The MR/MI population is not well served in this state. Given the recent budget cuts in mental health, this situation is not likely to improve.

Dr. K., midsouth state: As far as a state-wide system, there is no specific attempt to develop a cooperative system. There is an assumption that community mental health centers (CMHC's) are adequate to take care of the mental health needs of people with mental retardation. Multiple anecdotal reports would suggest that the CMHC's are not equipped to provide adequate care. The best system has been a contractual arrangement between the university and the state to provide psychiatric care for members of a federal lawsuit case. The number of patients which this arrangement serves is small, but the impact has been very helpful. The university collaboration project has been largely successful because the doctors have a multidisciplinary approach and encourage input from multiple sources. Attending the appointments with the patient are frequently a behavior analyst, a case manager, a nurse, and direct care staff. Results from each appointment are typed in a report and disseminated to the team members. The presence of behavior analysts has been a major contribution to the success of the program. Having Masters' level individuals in the home assessing the behavior and training the staff adds a lot of credibility to reports about the patient's behavior. This system is no doubt more expensive than what would be provided by Medicaid or managed care, but the system allows for the interdisciplinary cooperation which is the gold standard. The CMHC system probably fails because of a lack of education on the part of the providers on how to deliver high quality care to people with mental retardation, as well as a lack of fiscal incentive to provide that level of care.

What seem to be the major barriers to working out issues of service delivery to this complex group of individuals?

Paul Kolstoe, Ph.D., North Dakota: I mentioned earlier developments at my agency with our state hospital. Rural areas seem to have a paucity of specialists. My observations have been developed in the extreme rural areas of our wide open spaces of North Dakota, South Dakota, and Nebraska. Neither psychiatry nor psychology is prepared for people with developmental disabilities and their mental health needs. My internship was at a state hospital in South Dakota, and I've already mentioned my current experiences with our own state hospital. I find that people dealing in mental health as a primary focus have to move at a clinical speed that is generally too fast for many ("most of the people I'm familiar with) people with developmental disabilities.

1.The definition of "stable" when hospitalized is one point, for example. Often the stress of the person's home is a significant contributor to the current crisis. With hospitalization (or even jail), the person both experiences significant relief from the stress and "honeymoons" to the new environment. So they are "symptom free"-but their support network may be shambles. Our reimbursement system seems to underpay for people with DD in the first place, and places utilization expectations based upon the person's "hospitalization" behavior and not the total picture. I do not have an alternative to propose, as reasonable pressures to discharge must be in place. Further work need to occur to provide in-residence supports as well. However, there are many practical problems involved with living in a community of 2,000 people with the nearest hospital of any kind an hour away and an unemployment rate between 1-2%--severe over employment.

2.Also, our mental health practitioners do not get the experience with the DD population. Of 1,500 admissions across a year, only 20-30 have developmental disabilities-an "experience" proportion of 2%. This is normal, but for practitioners to develop any experience base-or to even take a minor interest in the subpopulation-is virtually impossible.

D. L. midwestern state: (in response to Paul Kolstoe's comments just above) You have represented a similar scenario to that of the __(state) experience for those with a dual diagnosis via my observations. It is inherent on the care givers, or those knowing the individual well, to help to nail down the problem and, oftentimes, through trial and error, to play a significant role in the development and execution of the remediation action plan as well. In defense of psychiatry, they have generally learned to be good listeners, and supportive of action plans developed by those who know the individual best. (It has sometimes been difficult for psychiatrists to recognize that they are a "part" of the team, as opposed to being the end-all decision maker.)

Dr. N., southern state: The state runs the state hospitals and the Community Services Boards run all community-based services. They do not talk to each other much. Further, neither group-MI nor MR-wants to take on the responsibility for providing services to those individuals that have both disorders.

Dr. S., southeastern state: To be totally candid, I cannot see any improvement coming in the foreseeable future. One reason is financial. Our state budget has been a mess and is even messier this year. Cutbacks-cutbacks-cutbacks. And one of the primary agencies getting financial hits is mental health, as well. They are very unlikely to open their doors to more clients; in fact just the opposite. At this point, my feeling is that the mental retardation system should handle everybody with mental health/mental retardation problems-except during short-term crisis intervention, when a bed and medication are temporarily needed. Although many of our staff have very limited expertise, at least they have interest and experience with this population, and that counts for a lot.

Theodosia Paclawskyj, Ph.D., Maryland: A major area of concern for me personally at this time is the delivery of emergency services. The needs that I currently see are as follows:

1.access to emergency room-based emergency psychiatric services (adult and pediatric) with trained staff, adequate facilities, and disposition options

2.access to mobile crisis-team intervention services (pediatric and adult) for non-life threatening psychiatric emergencies

3.single point-of-contact in state services to identify appropriate psychological and psychiatric providers for non-acute situations

4.availability of pediatric and adult emergency respite beds in a facility with adequate resources and trained staff

It is discouraging to think that much of this now exists only in fantasy. However, I think many of us are struggling to provide/access services in multiple states where the resources are below par. With some sort of global statement of needs, it may provide a possible framework for revising current systems through agreement on what should be available. Details could be state-specific, but access to services should be comparable across states.

Dr. B., midsouth state: One of the biggest issues/barriers is serving individuals that are not Class Members. They are often in as much distress but we are not funded to evaluate them and cannot offer follow up. Another barrier is lack of education. Some people serving the Class Members are unprofessional, unethical, and unqualified to serve complex cases, but the state tolerates this it seems, because there are too few agencies to provide services. This reluctance on the state's part is a huge barrier to getting good services. Abuse investigations are sometimes cursory and inadequate. The level of training needed to get professionals, direct care staff, and supervisory personnel up to an adequate level of competence is staggering. The state is not doing any short term or long-term staff training in our area and seems very uninterested in this endeavor. Lastly, staff seem so frozen by state regulations that they cannot practice with much creativity or flexibility in managing difficult cases. If it isn't poorly trained state nurses or state site inspectors with some type of bizarre agenda-as all autistic adults have to be involved in daily community activities often in crowded places like Wal-mart-direct care staff seem to move from one mandate to another.

Dr. A., eastern state: No one really wants them (these complex individuals). The attempt to throw them onto the other agency's budget remains, almost as a reflex, and prevents true cooperation. The people in the trenches who would want to foster the interagency cooperation have not the power to bring it about. There is also real hostility between the agencies after years of what each perceives (with some justification) as dumping of patients on each other.

Dr. K., midsouth state: The first barrier is probably a lack of will to spend the money that a quality system would require, as well as a failure to build a system which holds entities accountable and demands excellence. The university system requires a highly competent person to call a day in advance to confirm appointments and send out reports.

Dan Kauffman, Ph.D., Pennsylvania: The biggest barrier I see is funding. No one seems to want to use their money or resources on people who may only get counted as being served in one program and that may not be their program. Once special funds are set aside and provided, counties expect those funds every time a dually-diagnosed (DD) client is released from a hospital and are more than willing to wait until they get the funds. The client at least has a place to stay and food until they get that funding. I think the best practices idea is excellent. I believe, however, that people also need training, or at least encouragement to read about the different types of clients. I work with so many people who base their ideas of how people with MR behave and act based on DD clients. I think people need to have a basic understanding of mental retardation before they will understand how to work with DD clients.

John Jacobson, Ph.D., New York: Working out the specifics of responsibility on a case-by-case basis appears to be the primary concern-MRDD and MH agencies are often willing to assume joint responsibility, which is possible to do, but identifying which resources will be accessed from which agency requires extensive coordination-so perhaps local bureaucracy and turf concerns remain the primary barrier.

Stan Handmaker, M.D., New Mexico: There are inadequate resources, i.e., not enough properly trained professionals and very few mid-level (between inpatient hospital and home) facilities in place.

Neill Carson & Susan Morris, Toronto, Ontario: Work with people with dual diagnosis in Ontario takes place within a culture that on one hand supports collaboration and creativity and on the other suffers the burden of its own history. For example, it has been important to help our staff within the program to understand the system level dynamics because they have a direct bearing on the engagement process with referring agents. At the case level, we find that callers are often already sure that they understand the problem and know what the solution is. Most frequently, there is a belief that hospitalization is the only possible intervention. Callers may expect a magic pill or a magic diagnosis to transform the circumstances of their client-the callers may themselves be in crisis,, exhausted, and in many instances cynical about the capacity of a specialized service to help them in a meaningful way. At a staff level, an over-arching challenge is the complexity of the consultation role. New staff face a steep learning curve as they acquire new knowledge related to whichever (MH or MR) is not their field of expertise and also try to adjust to the consultant role. In addition to the need to learn a new way of working, there is also the expectation to acquire detailed knowledge of various clinical problems, such as disability issues, mental illness, genetic syndromes, and related medical conditions, as well as to integrate all this into a biopsychosocial and system framework.

Have you developed any cooperative programs to specifically serve individuals with "dual diagnosis" who are involved in the criminal justice system, and what specific resources do you think your state/province needs to improve cooperative services for these individuals?

Dr. N., eastern state: Not in _______. The main problem is the lack of adequate funding mechanisms that would integrate the two systems when dealing with this population. There is no incentive to serve this population because, in the end, they can languish in state psychiatric hospitals. So, making the money follow the individual would help.

Dr. K., midsouth state: Whenever a person with mental retardation and mental illness who has been allegedly abused in jail is featured on the front page of the newspaper, the state springs into action to help. Fortunately, this does not happen often, so there is no need to develop any programs.

Dr. S., southeastern state: Thanks to the efforts of Protection and Advocacy, people with mental retardation and "dual diagnosis" have received much more help and attention over the past decade, at least with respect to evaluations of Competency and Criminal Responsibility. Any person with mental retardation has to be evaluated by two psychologists from the Mental Retardation system. If the person is thought to have a mental health problem, we can either do a joint evaluation with the Mental Health forensic expert or do separate evaluations. If the case goes to court, both Mental Retardation and Mental Health evaluators are asked to testify. Usually, we have consulted beforehand and are in agreement about our determination. This has worked out very well for defendants with mental retardation. The mental health reports that used to be about several paragraphs long have become much more detailed over the years (they were obviously being embarrassed by the mental retardation professional's lengthy, detailed report).

Dr. B., midsouth state: No. My experience is seeing these individuals traded back and forth, and I work hard to get them out of the justice system into group homes.

Stan Handmaker, M.D., New Mexico: Yes. My suggestions for improvement in cooperative services for these individuals:

"training of professionals re diagnosis and treatment of this population

"ready availability of backup consultation for services in the local communities

"Halfway houses with staff trained to care for this population

John Jacobson, Ph.D., New York: The Department of Correctional Services operates several special needs units. Adjudicated or diverted individuals can be admitted to secure services operated at several locations by OMRDD, on several campuses. In the case of New York state, it seems clear that the infrastructure to serve these people exists, but that to assure high quality, extensive cross-training between MH and MRDD is needed in order to 1) assure they are speaking the same language, and 2) encourage mutual understanding and collaboration.

Robin Friedlander, M.D., Vancouver, BC: Programs have been developed for the mentally disorder offender, but more lobbying is going on re inappropriate confinement of DD clients by community advocates. There is no joint project re diversion/treatment between MOH, MSS, and the forensic/justice system.

Ann R. Poindexter, M.D.: In summary, there are many exciting "pockets" of innovative, apparently effective cooperative efforts between mental retardation and mental health agencies all around North America, as well as in other parts of the world. There are, of course, many problems. Some of the comments we've included in this dialogue are quite negative-and some of these come from the same states as some of the positive comments. Problem areas seem to generally stem from fiscal issues and lack of experience in dealing with these complex individuals, both from the mental retardation and mental health "sides." Certainly many discussants note the importance of improved training for everyone who works with this population-from direct support staff and families to professionals-and I truly believe that is doable.