The Seventh Annual Conference of the National Association for the Dually Diagnosed (Mental Illness/Mental Retardation)*

and to emphasise the strengths and shortcomings of the professional care available for them. In London, the running down of mental hospitals has superceded adequate community provision and homeless, mentally ill people often face extreme diffi culty in finding any sort of medical care. In recent years there have been severe cutbacks in the building of new houses. Housing corporations have reduced their funding and this has exacerbated the situation. Furthermore, public acceptance of mentally ill people in the community is difficult to achieve. The professional network for aftercare is sadly often deficient. The Department of Health has asked for new discharge policies, with particular em phasis for people with special needs, such as the homeless mentally ill, but at present only one London borough has a policy for the discharge of homeless patients. In Haringey, no Section 117 dis charge arrangements are available and statutory aftercare obligations fail because there are no approved social workers. Dr Weller spoke of the three main groups of homeless people: the young, often with problems of Conference briefings

and to emphasise the strengths and shortcomings of the professional care available for them.
In London, the running down of mental hospitals has superceded adequate community provision and homeless, mentally ill people often face extreme diffi culty in finding any sort of medical care. In recent years there have been severe cutbacks in the building of new houses. Housing corporations have reduced their funding and this has exacerbated the situation. Furthermore, public acceptance of mentally ill people in the community is difficult to achieve.
The professional network for aftercare is sadly often deficient. The Department of Health has asked for new discharge policies, with particular em phasis for people with special needs, such as the homeless mentally ill, but at present only one London borough has a policy for the discharge of homeless patients. In Haringey, no Section 117 dis charge arrangements are available and statutory aftercare obligations fail because there are no approved social workers.
Dr Weller spoke of the three main groups of homeless people: the young, often with problems of Conference briefings employment and finance, who are sometimes men tally ill; middle-aged people who are often chroni cally destitute, some 40% of these mentally ill, with 22% actively deluded or hallucinating, and a third group homeless as the result of drug or alcohol abuse, maybe a consequence of mental illness.
The number of prosecutions of homeless people has doubled over the last two years and the Metropolitan Police are very concerned about the extent of vagrancy. The rate of conviction is directly pro portional to the amount of homelessness and in versely proportional to availability of psychiatric beds.
CONCERN calls for emergency accommodation throughout the country, specifically for homeless mentally ill people; central funding for carers, a National Health Bed Bureau and provision from health authorities of some facility which can serve as a haven for mentally ill people with no fixed abode. It wants to see the closure programme for large city asylums postponed so that hospital and community facilities can run in parallel until such time that the community can manage independently.

N. BOURAS, Consultant Psychiatrist and Senior Lecturer, United Medical and Dental
Schools, Guy's Hospital, London SEI 9RT The National Association for the Dually Diagnosed (NADD) was started in the early 1980s by a small group of people who recognised the collective need for an awareness and understanding of the needs of people with a mental handicap who also had a mental illness. The intention was to bridge the gap between the primary service providers and therapists by high lighting important skill deficits whether oriented to mental health or mental handicap. The Boston conference was attended by over 300 participants of different disciplines, mainly from the USA and Canada, including psychiatrists, psychol ogists, other professional therapists, administrators, residential and day-care staff. The theme was 'Back to the Future, Lessons of the Past -Challenges of the Future'. The first keynote speaker, Professor Frank Menolascino of Nebraska University, referred to the fallacies of the past, such as the psychometric mental age as a measurement, untrainability and untreatability. He highlighted the need for future services to be small, integrated, using an array of options, 'Conference held in Boston, Massachusettsin December 1990.
focused on the development of long-term stable relationships, supported by regional tertiary care centres for short-term in-patient and long-term out patient treatment. The other keynote speaker, Dr Ludwig Szymanski of Children's Hospital, Harvard Medical School, drew attention to the training needs of mental health professionals and the necessity for interdisciplinary training schemes.
The 60 presentations were divided into nine symposia covering areas such as assessment and diagnosis, treatment methods with emphasis on pharmacotherapy, behaviour therapy, psycho therapy, therapeutic interventions for aggression and challenging behaviour, as well as organisation and delivery of services and techniques to train staff appropriate skills.
Dr Steven Reiss described the increasing use of standardised instruments for assessment of psychi atric disorders and presented a wealth of recent data on children and adults. The importance of accurate psychiatric diagnosis and the use of psychotropic medication based on current advances was empha sised by the main speakers in these subjects: Dr Robert Sovner and Dr Henry Crabbe. Dr William Gardner reviewed the perspectives of behavioural methods used to treat people with mental handicap and aggressive behaviour by presenting a compre hensive, functional analysis of aggression with em phasis on environmental factors. The model of service provision which prevailed was community based with admission facilities whenever necessary. The complexities, various and sometimes conflict ing principles and opinions of multidisciplinary team members were illustrated by Dr Mark Hauser.
It is encouraging and stimulating that an organis ation such as NADD exists which focuses its activi ties on important issues and dilemmas, presented by the combined disability of mental handicap and mental illness. Although the challenge of correct diagnosis of psychiatric disorders in people with a 287 mental handicap is not a new issue, it has received much more attention in recent years because the pro cess of deinstitutionalisation and community care has increased the visibility of the problem. The co existence of mental handicap and psychiatric dis order has serious effects on the person's daily functioning by interfering with educational and vocational progress by jeopardising residential placements, and by disrupting family and peer re lationships. It can also greatly reduce the quality of life of people affected.
More collaborative work on an international level is required to disseminate knowledge and encourage the exchange of ideas in the field. My only suggestion is that perhaps it is time for NADD to reconsider its name, especially as there is an element of ambiguity, which might be applied to other conditions and hence lead to confusion. adequately protected under the present legislation? He emphasised that civil rights were both positive, e.g. the right to care and to receive essential services as well as negative, such as the freedom to be pro tected from harm. How far patients were able to consent to treatment that impinged on their rights remained a matter of debate. Mr Bingley felt that there was a clear difference between those patients who were incapable of giving consent because of mental handicap or severe psychosis and those who were able to give consent but refused treatment. He believed that future revisions of the Mental Health Act should recognise the distinction between these two different sets of circumstances.

The Mental Health Act and its agencies
The work of the other main statutory agency, the Mental Health Review Tribunal, was discussed by Professor Sir John Wood, Chairman of this body. The most obvious injustices in the treatment of the mentally disordered patient arose because of deten tion in the wrong place because of lack of resources. The two basic rules that Sir John felt should always apply, that the patient should be kept in as free an environment as his illness permits and that once a move was indicated it should be offered with as little delay as possible, could often not be achieved because of the difficulty of arranging transfer to a less