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II A.Routine expectation of and welcome to treatment for both disorders

Element Details


Persons with co-occurring disorders are welcomed by the program or facility, and this concept is communicated in supporting documents. Persons who present with co-occurring substance use disorders are not rejected from the program because of the presence of this disorder.


Observation of milieu and physical environment, including posters on walls in waiting rooms and group rooms, as well as interviews with clinical staff, support staff, and patients.

Item Response Coding:

Coding of this item requires a review of staff attitudes and behaviors, as well as the program’s philosophy reflected in the organization’s mission statement and values.

  • Mental Health Only Services = (SCORE-1): Program expects mental health disorders only, refers or deflects persons with substance use disorders or symptoms. The program focuses on individuals with mental health disorders only and deflects individuals who present with any type of substance use problem.

  • (SCORE-2): Documented to expect mental health disorders only (e.g., admission criteria, target population), but has informal procedure to allow some persons with substance use disorders to be admitted. The program generally expects to manage only individuals with mental health disorders but does not strictly enforce the refusal or deflection of persons with substance use problems. The acceptance of persons with substance use problems likely varies according to the individual clinician’s competency or preferences. There is no formalized documentation indicating acceptance of persons with substance use problems.

  • Dual Diagnosis Capable = (SCORE-3): Focus is on mental health disorders, but accepts substance use disorders by routine and if mild and relatively stable as reflected in program documentation. The program tends to primarily focus on individuals with mental health disorders, but routinely expects and accepts persons with mild or stable forms of co-occurring substance use disorders. This is reflected in the program’s documentation and surroundings (e.g., on walls and brochure racks).

  • (SCORE-4): Program formally defined like DDC, but clinicians and program informally expect and treat co-occurring disorders regardless of severity, not well documented. The program expects and treats individuals with co-occurring disorders regardless of severity, but this program has evolved to this level informally and does not have the supporting documentation to reflect this service array.

  • Dual Diagnosis Enhanced = (SCORE-5): Clinicians and program expect and treat co-occurring disorders regardless of severity, well documented. The program routinely accepts individuals with co-occurring disorders regardless of severity and has formally mandated this aspect of its service array through its mission statement, philosophy, welcoming policy, and appropriate protocols.
Enhancing MHOS Programs

MHOS programs typically foster a more traditional ambiance and environment. This cultural “atmosphere” is focused on mental health issues and recovery only. Often this focus hampers a dialogue or openness about addiction problems or concerns. This milieu may not enable a patient to inquire about the potential for recovery from co-occurring substance use disorders.

MHOS programs seeking to become DDC must document, for example, in their admission criteria, that the program accepts individuals with mild or stable co-occurring substance use disorders. Programs can decrease the stigma and elevate the awareness of substance use disorders by providing brochures in waiting areas that describe alcohol or drug problems and recovery (e.g., AA and Al-Anon brochures). These subjects can also be routinely raised in orientation sessions, community meetings, or family visits. These practices explicitly convey a welcoming and acceptance of persons with substance use concerns or disorders.

The cultural undercurrent to a DDC program enables persons with co-occurring substance use problems to feel “normal.”

Enhancing DDC Programs

In order to become a DDE level program, DDC programs make a milieu or cultural shift to an equivalent focus on addiction and mental health disorders. Programs must demonstrate their acceptance of individuals with co-occurring disorders regardless of severity via mission or philosophy statements, admission criteria, or other documentation. Patients in DDC programs will report that they are in treatment to address a specific mental health concern, but they can also readily talk about substance use problems and ask questions about addiction consequences. Patients in DDE programs, however, are able to articulate that they have co-occurring disorders and they are getting treatment in both domains. They may contrast this with previous treatment experiences, and remark this is the first program that has addressed both disorders at the same time. Patients also report no stigma or differential status associated with having a co-occurring disorder.