Did You Know

Co-occurring Disorders and Evidenced-Based Practice

It is estimated that between 40% and 60% of persons with severe mental illness will develop a substance use disorder (SUD) at some time in their lives. These co-occurring disorders are consistently found to adversely impact the course of mental illness and response to treatment, psychosocial functioning, and cost of care. The literature on co-occurring disorders documents a number of common consequences of SUD in persons with severe mental illness. Among those documented include: housing instability, symptom relapse, treatment noncompliance, violent behavior or threats of violence, suicidal ideation or attempts, cognitive impairments, difficulty budgeting funds, prostitution, social isolation and social difficulties, employment difficulties, hygiene and health problems, and legal problems.

The literature identifies several critical components that have come to be defined as "evidence-based" practices in the provision of services to individuals with co-occurring disorders. Effective programs are defined by their assertive outreach, comprehensiveness, and their long-term perspective. Recovery from both serious and persistent mental illness and substance abuse is generally recognized not to be a linear process. The literature suggests that individuals with co-occurring disorders often have difficulty linking with services and participating in treatment and do not usually develop stability and functional improvements quickly. Effective programs therefore, are developed on a long-term community-based perspective, are comprehensive in nature integrating substance abuse and psychiatric interventions, and work assertively to engage and develop trusting relationships with the individuals they serve.

Successful programs have adopted a stage-wise treatment perspective that has been adapted from Prochaska and DiClemente's Stages of Change theory. Minimally, the stages include:

1. engagement, the development of a trusting relationship;
2. persuasion, helping the engaged consumer develop the motivation to actively pursue goal specific, abstinence oriented treatment;
3. active treatment, helping the motivated consumer develop the necessary skills and supports to attain desired treatment goals related to both mental health stability and substance use reduction/abstinence; and
4. relapse prevention, helping the consumer maintain treatment gains and avoid relapse.

Additional components include motivational interventions, counseling (cognitive/behavioral skill development in the active treatment stage), and social support interventions. Consumers with co-occurring disorders are often not ready or not motivated for abstinence mandated treatment programs and fall out of treatment that is not responsive to their needs. Motivational strategies help consumers identify goals and behavior patterns that impede the realization of these goals. Maintaining psychiatric stability and substance abstinence (recovery) requires the development of specific cognitive and behavioral skills. Programs must be able to identify skill deficit areas and help consumers relearn or acquire these necessary survival skills. The role of family and social support is a key factor in helping to maintain recovery and community residential stability. Strengthening the immediate social environment is an important part of helping individuals to change or modify their behavior.

Drake and his colleagues assert that a "consistent finding in the research is that programs that show high fidelity to the model described - those that incorporate more of the core elements [described above]- produce better outcomes than low fidelity programs."

Article excerpted from: Drake, et. al. (2001). Implementing Dual Diagnosis Services for Clients with Severe Mental Illness. Psychiatric Services, Vol. 52, No. 4.