This article emphasizes core philosophies and components of effective dual disorder programs.
Integrated dual disorder programs have come about because traditional treatment of co-occurring addiction disorders and psychiatric disorders fail in a large number of people and waste resources. More than 5 million adults in the United States have a serious mental illness and a co-occurring substance use disorder.1 About half of the people who have had a mental disorder in their lifetime have also had a drug or alcohol disorder, and vice versa.2 Many people with dual disorders are treated in expensive, ineffective, and unsatisfying ways-in emergency departments and hospitals, for example-rather than in community settings.3,4 This article emphasizes core philosophies and components of effective dual disorder programs.
Many people curtail the use of damaging drugs and alcohol on their own, and many people with mood and psychotic disorders recover.5 People can change if they believe that change is worthwhile-and if they are ready, willing, and able. But change demands time, vision, and tenacity. People with dual disorders are complex. They can be paranoid, impulsive, or depressed, or they can be withdrawing from a drug or have limited attention and planning capacity. They can also have problems in realms such as financial, legal, housing, or relationships.
How challenging it is for these people to make dramatic behavioral changes! Treatment needs to help them get there, but too often treatment programs demand exactly what people with dual disorders cannot do. If a program is to be effective in such a population, it must be able to grapple with these complexities.
Core values anchor a team and guide its practice. It helps to make those core values explicit. Ongoing education and supervision can refer to these values, and good practice will flow from them.
Treatment should be integrated. Psychiatric and substance abuse disorders affect each other’s emergence, course, and recovery. Psychiatry clinics commonly fail to assess and treat addictions, and addiction specialists can be poor at detecting and treating psychiatric disorders.6 One still hears comments such as, “You have to treat the addictions before you can treat the mood disorder,” or “She needs to confront the trauma and then she’ll stop using.” Treatment of addictions and psychiatric disorders then occurs in parallel or sequentially-but not in an integrated fashion. Frustrated clinicians blame failure on the other disorder, treatment philosophy, or the patient. Treatment retention is low and relapse and rehospitalization rates are high.
Complex problems cannot be addressed with simplistic solutions. Care should be integrated at the organizational, assessment, and delivery levels.7 Integration ensures that therapists can address the range of challenges facing a participant by using pharmacotherapeutic, motivational, and behavioral interventions.8 Assessments need to be comprehensive and cover substance use and psychiatric symptoms, risk level, and both internal and external challenges to recovery. Obtaining a chronology enables these challenges to be understood in the person’s narrative, reveals repeating patterns (eg, escalating psychosis after relapse to drinking and stopping medications), and suggests priorities on which to focus.
Treatment should be hopeful, respectful, and authentic. Strong predictors of deterioration within a treatment include lack of therapist-patient bonding; confrontation, criticism, and high emotional arousal; stigma; and low or inappropriate expectations.8 Hope derives from the knowledge that people recover despite difficult setbacks. Respect requires curiosity, consideration, and listening to the patient’s agenda, and acknowledging his or her strengths. Authenticity comes from genuine concern and being straightforward about objectives: people can sense when a therapist is being disingenuous. This is not to say that all feelings should be shared. Respectful boundaries must be observed and impressions should be shared to help only the participant and not the therapist.
Decision making should be a shared recovery perspective. The participant must feel that the clinician is working for him, rather than for mandated, impersonal goals. People may not view their condition as psychotic or addicted and may accordingly reject medications or therapies that target symptoms. Such patients are often labeled as lacking in insight, in denial, or nonadherent. But from their perspective, patients can feel misunderstood, alienated, and let down by psychiatry, their families, and society.9 Instead, therapists must appreciate the individual’s perspective and assist in the clarification of needs, wants, and valued goals within an empowering environment.10 Not all symptoms need to be treated, but certain deleterious behaviors and worldviews can hamper recovery.
In shared decision making, the team joins with the patient. The patient must be listened to and helped to articulate his values and goals. The treatment team can help break these down to manageable and measurable components. Then interventions are proposed that might facilitate the patient’s recovery and capitalize on the patient’s strengths. This way, interventions make sense and can be accepted.11 The goals may not always look traditional. For example, one patient wanted to consummate a relationship with a rock star because he believed this was destined. Interventions were framed to facilitate this, and they included improved hygiene and curtailing his overt responses to auditory hallucinations. Success encourages further collaboration. Skills and confidence permit patients to discover or strengthen other aspects of their personality and broaden their identity beyond just being mentally ill.
Involuntary interventions are sometimes necessary. These certainly challenge collaboration and trust. However, the program must be in alliance with the healthy and successful parts of the person. I let the participant know what actions would worry me and what actions or behaviors would make me commit them. The common goals are to avoid future loss of self-determination and to ensure safety. Of course, such discussion is redundant or even dangerous in an emergency situation. Advance directives can provide a template for collaboration.
Recovery should be viewed as a marathon and not a sprint. Long-term outcomes are good, but recovery is a long and inconsistent process that may take years.12 Identities may need redefining.13 This tough part of recovery will require trading immediate gratification for the pursuit of delayed but valued goals, learning and practicing new skills, and surviving relapses and hospitalizations. A program that provides support, education, and hope needs to accompany the patient through this journey. Ideally, it should provide continuous care through residential and community-based interventions. The patient and his family need to hear the long-term view to avoid being discouraged and feeling negative. Peers who have come a long way in their own recovery can inspire and relate in ways not possible by many staff members; and peer counselors, groups, and recovery organizations must be embraced.
Treatment should fit the participant’s motivation and goals. A program must be flexible and provide a menu of interventions to fit the participant’s goals.14,15 For example, it is pointless to talk of relapse prevention with someone who is actively abusing drugs. Before attempting to quit, the person needs to feel some ambivalence about his behavior. People rarely enter treatment eager to stop using drugs, and they sometimes do not accept that they are experiencing psychosis. They might be mandated or pushed into treatment, or else seek shelter, companionship, or relief from anxiety. For many people, drugs and alcohol become a way of coping, even while they contribute to their difficulties and make them reluctant to give them up. These people would be considered precontemplative in the Stage of Change Model.
Traditional treatment has demanded abstinence and considers anything less a failure. This view can be compared, for example, to cardiology clinics screening out patients who use salt. The United States has been tentative about embracing harm reduction, both at local and federal levels. But helping patients avoid hitting rock bottom is very different from enabling. Interventions such as education about safe injection practices or moderation management join with patients at their stage of change and in striving for their goals and improving therapeutic engagement toward further recovery efforts, while reducing overdoses and infections.16
Only when people experience the negative consequences of their behaviors and conflict with their values do they feel ambivalent, and their motivation to change behaviors increases.17 Empathic appreciation of the reasons for continuing behaviors decreases resistance so that people can see the downsides and the discrepancy between their behaviors and how they wish to be. Validation and affirmation strengthens resolve and confidence. Change becomes desirable and possible, and specific skills training can let it happen.18 Ongoing assessment is essential to match treatment goals to motivation, ability, and circumstances. Healthy resolution of such distress is thwarted by impulsive drug use; cognitive deficits; and limited ability to tolerate, modulate, and think through strong emotions and marked paranoia. Therapy needs to be slow, flexible, and wide-ranging to help such patients manage and change their behaviors.
After a thorough assessment, participants can be offered specific therapies to help them negotiate challenges and achieve set goals. Clinicians do not always take the time to share their reasons for selecting a particular approach (including medications); nevertheless, transparency allows the patient to clarify, select, and “buy in” to the treatment. Clinicians are often tempted to use therapies that worked effectively for previous patients, often without further rationale or ways to monitor and understand results.
Many manualized therapies have been tested and found effective. They tend to provide clear models, a treatment course, and a way to measure success. Undoubtedly, other therapies and approaches have merit (eg, 12-step fellowships, psychodynamic therapies). However, these techniques are not mutually exclusive and personal preference, alliance, and consistency need to be considered. Therapies that raise affect can trigger relapse and should be used in conjunction with stress management and relapse prevention. While no studies have addressed psychodynamic approaches with this dual-diagnosis population, many clinicians glean important information from the relational field. However, this information should be used carefully. Referring to the behaviors and emotions brought up between patient and therapist can be very stimulating and challenging. At times, such examples can illuminate important dynamics that impede the patient’s progress but, at other times, they can cause a rupture of the alliance, acting out of anxieties, or even relapse. There are often many examples to use from the patient’s life outside the psychiatrist’s office.
Medications are a cornerstone of effective treatment, and the psychiatrist should uphold the medical model as an essential perspective. Diagnosis of pathology directs treatment and permits risk assessment. It can also delay premature labeling. For example, staff members may interpret an act as proof of a personality disorder, but they should consider mania, paranoia, stimulant use, akathisia, or hyperthyroidism as possible causes.
Paranoia blocks alliance. Psychosis impairs attention and learning. Anxiety and insomnia exhaust. Depression impedes hope. Cravings and compulsion twist willpower. Medications can alleviate all these problems. Multiple and overlapping diagnoses are the rule, and the evidence base is scant when it comes to such complicated cases. It is sometimes necessary to treat symptomatically, until diminished drug use and time permit greater diagnostic certainty. Medications with strong supporting evidence that are still underused include the following:
• Opioid replacement therapies
• Agents that affect craving and cue responsivity, such as naltrexone
• Smoking cessation therapies
• Clozapine, which works for many treatment-resistant psychoses and appears to reduce illicit drug use19-22
Physicians also need to recognize and treat common medical and iatrogenic disorders (eg, sleep apnea, diabetes, movement disorders).
Patients resist medications because of fear of losing control, concern about adverse effects, and stigma of having a mental illness. Willpower and autonomy are revered in our culture and medications are often discouraged. This is particularly relevant in the realm of addictions where recovery is somehow seen as soiled if someone is taking medications, especially an opiate replacement, despite decades of evidence of efficacy.23
The psychiatrist needs to be collaborative and respect the participant’s priorities and worries rather than targeting a symptom. For example, an antipsychotic drug might be deemed unacceptable by the patient if it is recommended for delusions but accepted if it is prescribed to ease associated insomnia or anxiety. The full effect of a medication might be explained in a later phase of recovery when there is sufficient insight or alliance.
Prescribers should use the fewest number of medicines and discuss with the patient why they are choosing a particular drug, as well as its limitations and potential adverse effects. In this way, the patient becomes an active participant who knows his concerns will be listened to.
Education, symptom management, and skills training
Education (individually or in groups or via the Internet, books, and meetings with peers) helps families understand why the clinician is making a particular treatment choice. This knowledge can reduce shame and anger, and it can begin to unite families. Evidence-based practices often use cognitive and behavioral interventions in group or individual formats. The framework of interrupting automatic responses by reviewing triggers, thoughts, and feelings can be applied broadly. Manualized, time-limited applications are available for many disorders, including substance use, psychosis, and mood and anxiety disorders.24-26
Social skills deficits can affect the patient’s ability to blend in, have successful social interactions, and obtain jobs. Social skills training focuses on dress, conversation, and behavior to help the patient become more assertive and accepted-and also to navigate situations that might lead to drug or alcohol use.7 Cognitive deficits, common in schizophrenia, affect attention, memory, and planning; decrease the effectiveness of therapy; impair the patient’s ability to plan and finish tasks; and are associated with a poor prognosis. Direct advice, task analysis, and practice help.7 Cognitive remediation, either as a computer-based practice of cognitive tasks or via analysis and rehearsal of tasks of daily living, shows great promise.28
Residential care and assertive community treatment teams
Some patients may be motivated to transfer what they learn in a clinic to their outside lives. Many others, however, are precontemplative, highly paranoid, cognitively challenged, or have transportation or financial constraints. Assertive community treatment (ACT) teams go out to the patient, attempt to engage him, support his recovery in the real world, and introduce skills where application will be needed. Emergency coverage is always available. Patients may need help with practical issues, such as food and shelter, criminal charges, work, and relationships.
Because the work is intense, clinician to participant ratios are low (eg, 1:10). ACT teams are cost-effective, and they result in superior outcomes relative to standard care.29 Ideally, a team would work closely with a residential or inpatient program to provide continuity of care in case of acute deterioration.
Identity can easily become defined by addiction and mental illness. Work can bring self-respect, a sense of accomplishment, independent living skills, and interaction with a healthier peer group. A pay check is highly valued in our culture.30 Patients may need to learn skills, such as routine, attendance to hygiene, and symptom management, to succeed in the workplace. A vocational rehabilitation specialist can help patients identify their personal criteria and readiness, increase motivation, and forge relationships with employers. They often go out to the work site to provide on-site coaching and side-by-side facilitation. Work can start early in the recovery process, and skills and confidence increase gradually. Work can be broadly defined and might include shopping for neighbors or attending classes if such routine activities confer esteem and independence.
Families are often frustrated, alarmed, and demoralized, and they act accordingly. Expressed emotion, particularly criticism, correlates with early, frequent, and prolonged relapse, and poor medication adherence in patients with severe mental illness and addiction. Families may also express a desire for involvement that must be harnessed.31,32
Behavioral family therapies provide support and education and are solution-focused. They teach the family to communicate directly, to be tolerant, to be less critical and hostile, and to manage crises effectively. When a family’s coping skills improve, members can weather the turbulent course of recovery better. Multifamily groups enhance peer support, thereby reducing hospitalizations and improving medication adherence.33
Motivation and understanding can be high by the end of a session, but exposure to cues or stress can easily undo gains and push patients to pick short-term deleterious rewards (drugs or alcohol) over long-term goals (parenthood, work). In contingency management, the longer-term goals are broken down to smaller achievable steps, which are reinforced. Desired behaviors might be attendance or attention at meetings or negative urine toxicology results; rewards can be money, vouchers, or gifts.
Once staff members stop focusing on the negative, attention shifts to achievement. Contingency management has emerged as one of the most reliable interventions to reduce relapse.34 Outcomes are robust, and the process is considerably more enjoyable for all.
Morbidity and mortality are high among people with dual disorders, in part because of lifestyle issues (eg, smoking, poor diet, little exercise, sleep disorders, unsafe sex, possible suicide ideation, and medication-related adverse effects). Programs need to educate patients and offer them strategies for change. Smoking cessation should be provided in all programs. Safe injection practices, advice about driving while intoxicated, safer sex practices, and dietary guidance should be routine. Manuals can guide this process, and the team nurse plays a central role.35
Systems issues and anatomy of the team
The development of an effective dual disorders team requires time, commitment, and investment. Blending psychiatry and addiction teams can be difficult because of differing philosophies about confrontation, spirituality, and peer involvement. Integration must occur at financial and management levels and include multiple agencies to ensure multiple points of entry to care for people who may not know their problem a priori.36,37 Staff needs extensive and ongoing training to maintain a high fidelity to evidence-based practice models to ensure better outcomes.38 Involvement of peers who are advanced in their own recovery inspires hope, transfers expertise, and keeps the focus on patient goals; they are highly effective.39 A team approach with daily meetings provides a holding environment, coordinates care, and diffuses tensions. The use of group supervision can redefine the frustrations resulting from clashes between staff and patient agendas and suggests evidence-based solutions. While some specialization is necessary, all staff members should be skilled in most services. Care managers may have a closer relationship with their assignees, but ideally the patients should feel an alliance with the team rather than a particular individual. Staff members must be flexible, cooperative, patient, and respectful.
Not everyone needs all the components of care outlined here, but complex problems need complex solutions. Before a program is set up, it must be determined which patients it will help. Time, support, and structured treatment are needed, and this can be costly. If the investment is not made, however, the bill gets picked up by criminal justice, acute hospitals, or welfare services. Thus, the decision of whether to invest in effective dual disorder programs is one for health care systems and, ultimately, society. We have learned a lot about which programs work, and there are many patient “success stories” to show us how worthwhile these efforts are.
Drugs Mentioned in This Article
Naltrexone (Depade, ReVia)
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Mueser KT, Noordsy DL, Drake RE, Fox L. Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York: Guilford Press; 2003.
Wu P, Wilson K, Dimoulas P, Mills EJ. Effectiveness of smoking cessation therapies: a systematic review and meta-analysis. BMC Public Health. 2006;6:300.