Dual Diagnosis Enhanced Programs
Kenneth Minkoff, MD
In 2001, the American Society of Addiction Medicine Patient Placement
Criteria, Second Edition, Revised (ASAM PPC-2R) (American Society of
Addiction Medicine, 2001) introduced the concepts of dual diagnosis capa-
bility (DDC) and dual diagnosis enhanced (DDE) addiction programs into
the national lexicon. The original definitions of DDC and DDE addiction
programs were relatively brief.
DDC programs “address co-occurring ...disordersintheirpolicies
and procedures, assessment, treatment planning, program content, and
discharge planning” (American Society of Addiction Medicine, 2001, p.
362; Center for Substance Abuse Treatment, 2005, p. 33) so that program
staff are able to address co-occurring disorders routinely in relapse skills,
recovery environment, and readiness to change “through individual and
group program content.”
DDE programs are able to provide primary substance abuse treatment to
clients who are, as compared to those routinely treated in DDC programs,
“more symptomatic and/or functionally impaired as a result of their co-
occurring mental disorder” (American Society of Addiction Medicine,
2001, p. 10, Center for Substance Abuse Treatment, p. 33).
Nonetheless, the fundamental message was very important: co-occurring
disorder is an expectation in addiction treatment settings, and a continuum
of addiction programs needs to incorporate routine DDC into its full array
of services and plan for some DDE service components in order to provide
access to episodes of addiction treatment for individuals who would be
unable to receive treatment routinely in DDC programs. Further, fewer and
Kenneth Minkoff, MD, is Clinical Assistant Professor of Psychiatry, Harvard
Medical School, Boston, MA.
Address correspondence to: Kenneth Minkoff, MD, 100 Powdermill Road
# 319, Acton, MA 01720 (E-mail: kminkov@aol.com).
320
Journal of Dual Diagnosis, Vol. 4(3), 2008
Available online at http://jdd.haworthpress.com
C
2008 by The Haworth Press. All rights reserved.
doi: 10.1080/15504260802076314
Minkoff 321
fewer programs would be able to maintain themselves as “addiction only”
over time.
In the years since the release of the ASAM PPC-2R, the application
of the concept of DDC has become much more widespread and much
more clearly articulated. DDC as a concept is now routinely applied to
mental health programs (and both adult and child services), and previous
issues of this column have discussed the criteria for DDC implementation
at great length (Minkoff & Cline, 2006). Further, state and county systems
are working to develop infrastructures that would support all programs
developing DDC at minimum as a core expectation (Minkoff & Cline,
2004; 2005). Tools have been developed to allow programs to self-assess
for DDC (Minkoff & Cline, 2001) or to be assessed for DDC (McGovern,
Matzkin, & Giard, 2007). Several state and county systems have developed
system-specific regulations, program audit tools, and internal processes of
monitoring and technical assistance to support DDC development.
As more systems develop DDC as a universal feature, there is increasing
interest in “taking the next step” and starting to define program standards
for DDE programs, with the understanding that within a comprehensive
continuous integrated system of care (Minkoff & Cline, 2004), system
design should incorporate a small selection of DDE programs along with
universal attainment of DDC. Some systems have hypothesized that since
DDC programs can be created within base funding and base staffing, DDE
programs need to be defined by either additional funding; additional, more
highly trained staff; or both.
Although at first glance it makes sense for systems to want to create
“enhanced” programming, there is a significant problem with moving in
this direction, namely, that as yet there is no clear conceptualization o f what
DDE actually means, beyond the initial description in the ASAM PPC-2R,
which not only is quite brief but only applies to addiction programs.
Further, simply adding funding or adding more expensive staffing may not
produce good value without a clear model for program design that matches
the needs of the population being served and that is properly positioned
within the design of the larger system of care.
For this reason, it may be timely to dedicate this column to a broader
discussion of the meaning of DDE.
Let’s begin with a bit of history. The precursor to the concepts of DDC
and DDE dates back to a series of articles and publications during the
1990s (Minkoff, 1991; 1998). The description of basic and specialized
dual diagnosis programs throughout the system that was a key feature of
the 1998 report informed a consensus project in Massachusetts (Barreira,
322 JOURNAL OF DUAL DIAGNOSIS
Espey, Fishbein, Moran, & Flannery, 2000) that produced a system de-
sign template (Minkoff, 1999) that included a description of an array of
what would now be termed DDC and DDE programs. This work presaged
and informed the development of the ASAM PPC-2R (Minkoff, Zweben,
Rosenthal, & Ries, 2003).
These original conceptualizations allow us to understand more clearly
the nature of DDE programs. First and most important, there was originally
a clear distinction between DDE mental health (MH) programs and DDE
chemical dependency (CD) programs. This will be described in more detail
in the next few paragraphs.
DDE-CD programs, as described in the ASAM PPC-2R, were intended
to characterize addiction treatment programs (or tracks in programs), at
any level of care, that are designed to provide addiction treatment to a full
cohort of clients with co-occurring disorders and moderate to severe active
psychiatric symptomatology or baseline psychiatric disability. Examples
of such clients would be individuals seeking addiction treatment who also
had active post-traumatic stress disorder symptoms with significant flash-
backs and nightmares or individuals seeking addiction treatment who also
had baseline schizophrenia with moderate impairment. In general, such
individuals as a group require a higher staffing ratio than DDC programs
(which routinely work with individuals with co-occurring disorders with
only mild to moderate impairment) as well as greater on-site access to
staff with MH expertise, more program modifications, smaller groups, and
so on. DDC programs can often accommodate an occasional individual
client with a higher level of need, but cannot manage a full cohort of such
clients without the full range of accommodations mentioned above. Note
that simply adding more staff alone or hiring more highly trained staff
alone does not result in a DDE-CD program. What is critical is that the
program itself is designed at every level to match the functional needs of a
more impaired population in a n addiction treatment environment.
In short, DDE-CD programs have a higher resource requirement than
DDC-CD programs and a slightly different staffing mix, but the program
content (e.g., addiction treatment groups, MH symptom management, and
skill building) is fairly similar. In addition, just as in a DDC-CD program,
all staff still need to have core competency working with co-occurring
individuals; however, with a higher staff ratio there will be better ability
to assist individuals who need more structure or support to learn how to
manage their addiction effectively.
DDE-MH programs, by contrast, were originally conceptualized quite
differently. These were program models that were for the most part intended
Minkoff 323
to enhance the addiction treatment content of a standard MH program (of
any type) within existing resources. The clearest example to illustrate this
concept would be a DDE inpatient psychiatric unit, in which the pro-
gramming on the unit provides reasonably full addiction content at the
same cost as a standard DDC psychiatric inpatient unit (which would
be working with patients who may be less willing or able to engage in
addiction-related programming while in acute care) (Minkoff, 1989; Ries,
et al., 2001). In the same manner, one could contrast a DDE partial hos-
pital program, day treatment program, group residential program, and
so on with its DDC counterpart based on the intensity of the addiction
content in the program and the extent to which the program is specifi-
cally focused on providing such content to individuals with co-occurring
disorders. Again, note that simply hiring more staff with an addiction
background does not create a DDE-MH program; the critical feature is
redesigning the program content (policies, procedures, manuals, groups,
etc.) and function to have a greater focus on integrating specific attention to
addiction treatment needs within an MH setting. All staff still need to have
fundamental co-occurring disorder competencies (just as in a DDC-MH
program), but they will be operating within a program that has different
content.
Although the line between DDC and DDE-MH programs is relatively
clear in programs with highly structured program content, the distinction
becomes more blurred in looking at outpatient or case management pro-
grams. For example, a DDC assertive community treatment (ACT) team
will be routinely working with a high percentage of individuals with co-
occurring disorders as well as individuals without co-occurring disorders
and will routinely need to meet some of the fidelity criteria for integrated
dual disorder treatment (IDDT) teams in order to meet fidelity criteria for
ACT. A full-fledged IDDT team, however, which could be considered a
DDE program, is very similar to a DDC ACT program except that it con-
centrates exclusively on individuals with co-occurring disorders and meets
more of the IDDT fidelity criteria (Drake & Burnette, 2001) In this regard,
the distinction is more one of degree than of fundamental program design.
The lesson to be learned from this discussion is primarily that the concept
of DDE is fairly complex, and the definition of DDE will vary significantly
depending on the type of program being discussed. Therefore, it is much
more difficult (if not impossible) to establish a single set of DDE criteria
than it is to establish a set of DDC criteria, either in developing an assess-
ment tool for program capability (e.g., the Comorbidity Program Audit
and Self-Survey for Behavioral Health Services [Minkoff & Cline, 2001]
324 JOURNAL OF DUAL DIAGNOSIS
and the Dual Diagnosis Capability in Addiction Treatment [McGovern
et al., 2007]) or in developing program standards within a system of care.
For this reason, it is inaccurate to conceptualize or measure DDE simply
along a linear continuum on which DDC is the halfway mark. Rather,
progress toward DDC can occur in any program by increasing progress
in organizing core policies, procedures, and practices (Minkoff & Cline,
2006), while measurement of DDE standards needs to look at qualitatively
different program features.
In conclusion, therefore, this column is intended to be an introduction
to a deeper understanding of the concept of DDE programs. As more and
more systems make progress toward universal co-occurring disorder or
DDC, there will be increasing interest in further delineating the character-
istics not just of DDE programs generally but the specific characteristics
of different types of DDE programs at different levels of care in both sub-
stance abuse settings and MH settings. As these characteristics are more
clearly described and studied for each program type, standardized program
assessments and program criteria for each type of DDE program can be
more accurately developed.
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substance abuse and serious mental illness service delivery systems: Initiating a statewide
collaborative. Journal of Behavioral Health Services Research, 27, 107–113.
Center for Substance Abuse Treatment. (2005). Substance abuse treatment for individuals
with co-occurring disorders. Treatment improvement protocol 42. Washington, DC:
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Drake, R. E.,& Burnette, M. (Eds.). (2001). Integrated Dual Disorders Treatment Toolkit.
Rockville, MD: Substance Abuse & Mental Health Services Administration.
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