Treatment Approaches for the Dually Diagnosed:
The Problem of Co-occurring Addictive and Mental Disorders - continued

Integrated or Hybrid Treatment Approaches for the Dually Diagnosed

In response to the realities described above, the mental health literature of the 1990's has focused on innovative treatment approaches for the dually diagnosed (Brady, et al. 1996; Carey, 1996; Minkoff, 1991, 1989; Osher & Kofoed, 1989). These integrated treatment approaches attempt to combine treatment for substance abuse with treatment for mental illness. This integration, or hybrid model, allows the clinician to titrate specific treatments for each disorder when both are present (Ridgely, 1991).

Drake, et al. (1996) report that more than 30 studies had been done assessing the efficacy of integrated treatment for the dually diagnosed. While there are significant methodological weaknesses in many of these studies, i.e., lack of control groups, small sample size, brief follow- ups; the evidence from these studies suggest that the dually diagnosed can be engaged in treatment designed for co-occurring disorders and appropriately tailored for the individual's motivational stage; can be stabilized in outpatient community treatment with minimal inpatient care; and that recovery from substance abuse is associated with positive outcomes in other life domains (Drake, et al., 1996).

Early controlled studies reported a decrease in inpatient utilization for those individuals who remained in hybrid dual diagnoses treatment. An interesting finding is that of 13 NIMH funded national demonstration projects between 1987 and 1990. These programs targeted a myriad of high risk dually diagnosed groups and had the following consistent outcomes: the programs were all successful in engaging patients in dual diagnosis outpatient treatment with retention rates of approximately 80% over a one year follow-up; as mentioned above, patients successfully engaged in outpatient dual diagnosis treatment showed a decrease in their inpatient utilization rates; study participants showed minimal or no decrease in rates of substance use over the one year period indicating that patients were not motivated to participate in abstinence oriented treatments (Drake, et al., 1996). This last finding was significant in that it led researchers to recognize that new motivational approaches were necessary to engage and prepare dually diagnosed clients for substance abuse treatment.

Finally, in a preliminary analysis of the data from a three year follow-up study in New Hampshire, Drake, et al., (1996) report that hospitalization rates were dramatically reduced during the first 6 months of the study; global improvements in functional status were continuous throughout the three years; most of the clients moved through the motivational stages of substance abuse treatment; and approximately one half of the study participants attained some degree of abstinence by the end of the three years.

Minkoff (1989) describes the most complete philosophy of an integrated treatment model. His model is based on the integration of the AA 12-step disease-and-recovery model of addiction treatment and the biopsychosocial illness-and-rehabilitation model for the treatment of serious and persistent mental illness (Minkoff, 1989). For Minkoff, the disease concept of addiction and the illness concept of psychiatric disorder have a number of parallels which enable specific treatment strategies from each field to be integrated together into a single strategy for the dually diagnosed client. Parallel concepts of the illnesses include:

• a complex, multifactorial etiology, in which a hereditary or congenital biologic predisposition interacts with psychosocial stressors to result in the emergence of symptoms;
• once established, the presence of an underlying biologic process requires treatment to stabilize acute symptoms;
• the patient needs to be engaged in a rehabilitation or recovery process, rather than treatment to undo the etiology to obtain a cure;
• denial is a prominent characteristic of illness in each model, and overcoming denial is the first major task of treatment;
• the impact of the illness on patients and families produces feelings of shame, guilt, stigma, and despair, and these feelings must also be addressed in treatment;
• both psychosis and addiction are characterized by loss of control of particular aspects of thinking (psychotic symptoms) and behavior (inability to regulate substance use), which is related to the underlying biologic process of the disease;
• in each model the patient is powerless over the primary disease - powerless over the reality of having the illness and powerless to cure it; powerless to consistently control the symptoms of the disease and powerless to consistently prevent harmful consequences of those symptoms;
• powerlessness is not equated with hopelessness; patients can regain control by accepting their powerlessness, accepting the illness, asking for help, and actively participating in treatment (Minkoff, 1989).

Numerous researches have described their treatment programs as an ongoing process of moving through distinct stages of recovery (Brady, et al. 1996; Carey, 1996; Minkoff, 1991; 1989; Osher &Kofoed, 1989). Engagement in treatment, stabilization of acute symptomatology, the development of relationship, motivational interventions to encourage treatment participation, recognition of the heterogeneity of dual disorders, and crisis response services are all key elements of treatment strategies. While differences appear in the literature regarding number and definition of stages, they can generically be described as engagement, persuasion, assessment, concomitant treatment, and relapse prevention or aftercare (Ridgely, 1991). Additionally, some researchers have applied Prochaska and DiClemente's (1992) transtheoretical model of changing addictive behavior to these stages, emphasizing that the conceptualizations of precontemp1ation, contemplation, active change, maintenance, and relapse can help clinicians develop appropriate interventions at each stage that are specifically designed for the clients stage of readiness to change behavior (Brady, 1996; Carey, 1996).

Assessment is a process that must occur continuously across all treatment stages. The goal being a clearer understanding of the psychiatric diagnosis and the severity of the substance abuse problem. Assessment should help the clinician make decisions about treatment interventions. It is critically important to distinguish between primary disease and secondary symptoms (Minkoff, 1989). For example, some patients may develop affective and psychotic disturbances secondary to their substance use. Abstinence may resolve the secondary symptoms without the need for pharmacotherapy. The obvious treatment implications are for the emphasis of addiction treatment for these patients (Minkoff, 1989). However, some patients may have a coexistent primary psychosis that abstinence will not resolve. These patients will need a more integrated treatment program addressing both addiction and mental illness simultaneously (Minkoff, 1989).

Some patients with primary mental illness may use drugs or alcohol in a relatively controlled manner. These patients would be diagnosed with a primary psychotic disorder and a secondary substance abuse disorder. Again, treatment implications would be to target mental health treatment more aggressively, with an educational component regarding the deleterious effects of substance use on the course of mental illness as a way to encourage better decision making around substance use (Minkoff, 1989). And finally, some patients with primary mental illness will abuse substances to the extent of loss of control in the face of harmful consequences (incarceration, homelessness) and take the diagnosis of two primary illnesses, psychotic disorder and addiction disorder. These clients will need aggressive treatment in the integrated model for both disorders (Minkoff, 1989). A clear benefit of this model is its focus on the continued assessment of psychiatric symptomatology and other psychosocial functioning as it is impacted upon by abstinence or use and abuse of alcohol and drugs.

The literature demonstrates that mental illness and addictions are almost by definition characterized by relapse. This model of treatment defines relapse in the context of treatment interruption and proposes that the task of engagement (beyond that of establishing a positive working alliance) is to help the client reenter treatment, rather than terminating treatment, labeling the client noncompliant or a failure. Reentry is seen as a new opportunity to build on the treatment gains of the past (however small they may be). Indeed, in a case management/drop-in center program for the homeless mentally ill in West Philadelphia, case managers and clients (many of whom are dually diagnosed) often update on a weekly basis treatment plans that state, "client will produce 1 -2 clean urines per week", emphasizing that abstinence even for one day a week is positive progress.

Engagement can also be characterized by approach-avoidance behavior on the part of the client (Ridgely, 1991). Addiction treatment is often times characterized by repeated cycles of detox and relapse, and the mentally ill too often experience cycles of medication noncompliance and repeated hospitalizations (Minkoff, 1989). Many patients in the traditional treatment system often bounce from one agency to the next, after repeated failures at medication compliance or total abstinence from drug and alcohol use. The importance of long-term treatment relationships cannot be stressed enough in an integrated model in terms of positive long-term treatment gains.

Patients often need to be convinced that the treatment program has something to offer them. Some programs stress the need to provide clients with alternative activities, such as socialization and recreational activities (Osher &Kofoed, 1989). These activities serve a dual purpose, first, to provide incentive for treatment participation, and secondly, to provide alternative choices to daily drug and alcohol use. Further along in treatment these activities can be substituted with orientation to community 12-step groups or other community based sober recreational/leisure time activities. The persuasion stage is generally geared toward motivating the client to accept and participate more actively in either mental health treatment, addiction treatment, or both. Obviously the stages described in these integrated treatment models are not clearly delineated as separate and distinct of one another. The stages are over lapping as are some of the clinician tasks from stage to stage. It is also not unlikely for clients to move back and forth through the stages at various points in their treatment. Individual psychotherapy, low intensity level psychoeducational groups, peer support, motivational interventions, and a harm reduction approach are all appropriate interventions at this stage.

Motivational interventions are based on a social learning perspective in contrast to a disease model, and are designed to minimize resistance to change (Carey, 1996). Carey states that it is assumed that clients are ambivalent about changing their substance use (if at all accepting it as a problem), and they must come to their own conclusion about the need to change. The clinicians' job is to help the dually diagnosed patient make connections between their substance use and the continued non-attainment of important life goals (or continued exacerbation of psychiatric symptoms and re-hospitalization). Collaboration between client and clinician, not confrontation is the key ingredient in this process.

The underlying philosophy of harm reduction is that substance use exists on a continuum of abstinence to problematic use or abuse (Carey, 1996). Movement toward the reduced use of addictive substances is thoroughly encouraged, believing that successful reduction in frequency and quantity of use is likely to reduce negative consequences for the client (Carey, 1996). This philosophy allows for the client to develop incremental treatment goals toward the reduction of use, but more importantly, to have successful experiences of achieving treatment goals, and not being labeled a treatment failure.

Concomitant treatment, active treatment, and prolonged stabilization are all used to describe the next stage of treatment in the integrated approach (Ridgely, 1991; Osher &Kofoed, 1989; Minkoff, 1989). This stage description is a bit misleading as everything up to this point has clearly been treatment. Interventions similar to the ones described above are continued through this stage of treatment, as are interventions designed to encourage long-term behavioral change. Interventions tailored to client's specific diagnoses based on considerations of Minkoff's description of the parallel disease process noted above, and a focus on maintaining stability in terms of psychiatric and substance treatment gains will be the focus of this phase.

Ongoing mental health treatment, especially medication management is important to help the dually diagnosed client maintain a level of psychiatric stability in the community. Ongoing substance abuse treatment is integrated throughout treatment, including alcohol and drug education, especially regarding the specific effects of alcohol and drugs on individuals with brain disorders and the possible negative interactions with psychotropic medications (Ridgely, 1991). Case management and crisis intervention components are integral components of an integrated approach and help to maintain treatment continuity and client follow-up upon relapse or rehospitalization (Minkoff, 1989). The development of positive social networks is also an important reinforcer of treatment gains. One of the most accurate predictors of substance use is a substance using/abusing peer group. Client integration into the 12-step community of AA/NA and more importantly double trouble groups can be a valuable resource for helping the dually diagnosed maintain sobriety (Osher & Kofoed).

Finally, as with all treatment approaches for substance abuse or mental illness, the final stage in the integrated approach is relapse prevention and aftercare. In actuality, relapse prevention is continually addressed throughout all treatment phases. As noted above, addiction and mental illness are often characterized by relapse and decompensation. As such prevention strategies are built into ongoing interventions and cognitive and affective responses to relapse are closely monitored throughout treatment as these responses are often predictors of the degree to which the patient will return to former use/abuse patterns (Osher & Kofoed). Additionally, medication compliance must also be monitored and patient input as to the negative side effects of medication management must be taken seriously, emphasizing the collaborative nature of the relationship.

Conclusion

Numerous advantages of the integrated or hybrid approach versus treatment in the traditional mental health/addiction system for the treatment the dually diagnosed have been discussed above. To briefly summarize: the research indicates that an integrated approach tends to foster more clear positive outcomes over time for those patients engaged in treatment; it takes into account the psychiatric symptomatology of the client, i.e., audio and visual hallucinations, paranoid and delusional thinking, and other cognitive deficits, and stresses the importance of engagement and relationship building as necessary components of treatment; it stresses a commitment to the maintenance of a long-term therapeutic relationship, focusing on client strengths and accomplishments, as opposed to failure; it is collaborative and motivational, not overly confrontational, stressing the importance of accepting the client where he or she is and moving forward from that point; and it respects the best of both treatment systems and tailors intervention to the individual needs of the client.

Additionally, the simultaneous treatment of the dually diagnosed under one supervisory umbrella allows for more comprehensive assessment and treatment to occur, minimizing inter- agency miscommunication, and promoting better follow-up via case management personnel. Specially trained dual clinicians can better understand the symptomatology and unique problems associated with each disorder and thereby provide comprehensive integrated treatment to clients.

One would hope that we have learned from the process of deinstitutionalization in this country that the seriously and persistently mentally ill need ongoing intensive, comprehensive, and integrated support services if they are to maintain a high quality of life in the community. It is obvious that the same is true for the treatment needs of the dually diagnosed. That so many mentally ill and dually diagnosed individuals suffer deplorable living and treatment conditions (and have so historically in this country), is no less than a sin for which the professional treatment community must some day atone. While it may be true that most of the backwards of our psychiatric hospitals are empty, what is also true is that our streets are filled with psychiatrically disabled individuals (many of whom are dually diagnosed) with little or no access to treatment or housing. There is a large population of mentally ill individuals living in run down and ill equipped boarding homes with little or no access to treatment and certainly limited compassionate staff.

While the professional literature is encouraging to read, I wonder about the real numbers of dually diagnosed individuals across the country at large who have access to these types of hybrid interventions. My most pressing concern now in this era of federal, state, and local budget cutting, and with the current emphasis in medical and behavioral health care on profit; is how long will the dually diagnosed have the luxury of failing in their HMO mandated treatment programs 2,3, and 4 times before they are once again labeled treatment resistant and treatment failures, only to be cast back into the street (or to our jails) from where they most probably initially surfaced for treatment?

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