The term dual diagnosis is a common, broad term that indicates the simultaneous presence of two independent medical disorders. Recently, within the fields of mental health, psychiatry, and addiction medicine, the term has been popularly used to describe the coexistence of a mental health disorder and alcohol and other drug (AOD) problems. The equivalent phrase dual disorders also denotes the coexistence of two independent (but invariably interactive) disorders and is used interchangeably here with dual diagnosis.
The acronym MICA, which represents the phrase mentally ill chemical abusers, is occasionally used to designate people who have an AOD disorder and a markedly severe and persistent mental disorder such as schizophrenia or bipolar disorder. A preferred definition is mentally ill chemically affected people, since the word affected better describes their condition and is not pejorative. Other acronyms are also used: MISA (mentally ill substance abusers), CAMI (chemical abuse and mental illness), and SAMI (substance abuse and mental illness).
Common examples of dual disorders include the combinations of major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism and polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse. Although the focus of this volume is on dual disorders, some patients have more than two disorders, such as cocaine addiction, personality disorder, and AIDS. The principles that apply to dual disorders generally apply also to multiple disorders.
The combinations of AOD problems and psychiatric disorders vary along important dimensions, such as severity, chronicity, disability, and degree of impairment in functioning. For example, the two disorders may each be severe or mild, or one may be more severe than the other. Indeed, the severity of both disorders may change over time. Levels of disability and impairment in functioning may also vary.
Thus, there is no single combination of dual disorders; in fact, there is great variability among them. However, patients with similar combinations of dual disorders are often encountered in certain treatment settings. For instance, some methadone treatment programs treat a high percentage of opiate-addicted patients with personality disorders. Patients with schizophrenia and alcohol addiction are frequently encountered in psychiatric units, mental health centers, and programs that provide treatment to homeless patients.
Patients with mental disorders have an increased risk for AOD disorders, and patients with AOD disorders have an increased risk for mental disorders. For example, about one-third of patients who have a psychiatric disorder also experience AOD abuse at some point which is about twice the rate among people without psychiatric disorders. Also, more than half of the people who use or abuse AODs have experienced psychiatric symptoms significant enough to fulfill diagnostic criteria for a psychiatric disorder although many of these symptoms may be AOD related and might not represent an independent condition.
Compared with patients who have a mental health disorder or an AOD use problem alone, patients with dual disorders often experience more severe and chronic medical, social, and emotional problems. Because they have two disorders, they are vulnerable to both AOD relapse and a worsening of the psychiatric disorder. Further, addiction relapse often leads to psychiatric decompensation, and worsening of psychiatric problems often leads to addiction relapse. Thus, relapse prevention must be specially designed for patients with dual disorders. Compared with patients who have a single disorder, patients with dual disorders often require longer treatment, have more crises, and progress more gradually in treatment.
Psychiatric disorders most prevalent among dually diagnosed patients include mood disorders, anxiety disorders, personality disorders, and psychotic disorders.
Substance abuse complicates care for the person with mental illness. Diagnosis is difficult because it takes time to unravel the interacting effects of substance abuse and the mental illness. They may have difficulty being accommodated at home and may not be tolerated in community residences of rehabilitation programs. They lose their support systems and suffer frequent relapses and hospitalizations. Violence is more prevalent among the dually diagnosed population. Both domestic violence and suicide attempts are more common, and of the mentally ill who wind up in jails and prisons, there is a high percentage of drug abusers.
Many families do not recognize that their mentally ill member also has a substance abuse problem. This is because many of the behavioral changes that lead to suspicion of drug problems in other people already exist in persons with mental illness. Therefore, such behaviors as being rebellious, argumentative, or “spacey” may be less reliable clues.
Observation of some of the following behaviors, however, may put families on the alert:
- Suddenly having money problems
- Appearance of new friends
- Valuables disappearing from the house
- Drug paraphernalia in the house
- Long periods of time in the bathroom
- Dilated or pinpointed eyes
- Needle marks
Drugs might be used recreationally and their continued use might arise from their attempt to self-medicate themselves to treat anxiety and depression.
Continued drug use might arise because of isolation and marginalization.
There is a theory that individuals affected with both disorder have a certain vulnerability predisposing them to both.
Another theory holds that the patient had the substance abuse problem first which affected his or her brain functioning and behavior, leading to a mental illness.
Identification of both) disorders is often overlooked if seeking treatment for one of the conditions. Also, because many of the symptoms are similar, one of the diagnosis might be missed.
As many have probably discovered, service systems have not been well designed with this population in mind. Typically a community has treatment services for people with mental illness in one agency and treatment for substance abuse in another. Clients are referred back and forth between them in what some have called “ping-pong” therapy. What are needed are “hybrid” programs that address both illnesses together. Development of these programs locally requires considerable advocacy efforts.
Patients are often very reluctant to engage in treatment and once in therapy are often not tolerated in a rehab program or at home and often relapse. Sometimes if both problems are recognized, the patient alternates between both treatments, or he or she might be refused treatment for both. Traditional drug therapy might be too confrontation for someone with a mental illness and might produce symptoms of stress resulting in a relapse.
A more gradual treatment program is preferred. An illness model rather than a moralistic model of the problem should be used. Either inpatient or outpatient therapy may be recommended depending on the severity of the disorder.
For people with dual disorders, the attempt to obtain professional help can be bewildering and confusing. They may have problems arising within themselves as a result of their psychiatric and alcohol and other drug (AOD) use disorders as well as problems of external origin that derive from the conflicts, limitations, and clashing philosophies of the mental health and addiction treatment systems. For example, internal problems such as frustration, denial, or depression may hinder their ability to recognize the need for help and diminish their ability to ask for help. A typical external problem might be the confusion experienced when individuals need services but lack knowledge about the different goals and processes of various types of available services. Other problems of external origin may be very fundamental, such as the inability to pay for child care services or the lack of transportation to the only available outpatient program.
Historically, when patients in AOD treatment exhibited vivid and acute psychiatric symptoms, the symptoms were either: 1) unrecognized, 2) observed but misdescribed as toxicity or “acting-out behavior,” or 3) accurately identified, prompting the patients to be discharged or referred to a mental health program. Virtually the same process occurred for patients in mental health treatment who exhibited vivid and acute symptoms of AOD use disorders.
Mislabeling, rejecting, failing to recognize, or automatically transferring patients with dual disorders can result in inadequate treatment, with patients falling between the cracks of treatment systems. The symptoms of psychiatric and AOD use disorders often fluctuate in intensity and frequency. Current symptom presentation may reflect a short-term change in the course of long-term dual disorders. Thus, even when patients receive traditional professional help, treatment may address only selected aspects of their overall problem unless treatment is coordinated among services including AOD, mental health, social, and medical programs.
As a result, the treatment system itself may be a stumbling block for some people attempting to receive ongoing, appropriate, and comprehensive treatment for combined psychiatric and AOD use disorders. Thus, treatment services for patients with dual disorders must be sensitive to both the individual’s and the treatment system’s impediments to the initiation and continuation of treatment.
Treatment Systems: Mental Health, Addiction, And Medical
People with dual disorders who want to engage in the treatment process (or who need to do so) frequently encounter not one but several treatment systems, each having its own strengths and weaknesses. These treatment systems have different clinical approaches.
The Mental Health System
Actually, there is no single mental health system, although most States have a set of public mental health centers. Rather, mental health services are provided by a variety of mental health professionals including psychiatrists; psychologists; clinical social workers; clinical nurse specialists; other therapists and counselors including marriage, family, and child counselors (MFCCs); and paraprofessionals.
These mental health personnel work in a variety of settings, using a variety of theories about the treatment of specific psychiatric disorders. Different types of mental health professionals (for example, social workers and MFCCs) have differing perspectives; moreover, practitioners within a given group often use different approaches.
A major strength of the mental health system is the comprehensive array of services offered, including counseling, case management, partial hospitalization, inpatient treatment, vocational rehabilitation, and a variety of residential programs. The mental health system has a relatively large variety of treatment settings. These settings are designed to provide treatment services for patients with acute, subacute, and long-term symptoms. Acute services are provided by personnel in emergency rooms and hospital units of several types and by crisis-line personnel, outreach teams, and mental health law commitment specialists. Subacute services are provided by hospitals, day treatment programs, mental health center programs, and several types of individual practitioners. Long-term settings include mental health centers, residential units, and practitioners’ offices. Clinicians vary with regard to academic degrees, styles, expertise, and training. Another strength of the mental health system is the growing recognition at all system levels of the role of case management as a means to individualize and coordinate services and secure entitlements.
Medication is more often used in psychiatric treatment than in addiction treatment, especially for severe disorders. Medications used to treat psychiatric symptoms include psychoactive and nonpsychoactive medications. Psychoactive medications cause an acute change in mood, thinking, or behavior, such as sedation, stimulation, or euphoria.
Psychoactive medications (such as benzodiazepines) prescribed to the average patient with psychiatric problems are generally taken in an appropriate fashion and pose little or no risk of abuse or addiction. In contrast, the use of psychoactive medications by patients with a personal or family history of an AOD use disorder is associated with a high risk of abuse or addiction.
Some medications used in psychiatry that have mild psychoactive effects (such as some tricyclic antidepressants with mild sedative effects) appear to be misused more by patients with an AOD disorder than by others. Thus, a potential pitfall is prescribing psychoactive medications to a patient with psychiatric problems without first determining whether the individual also has an AOD use disorder.
While most clinicians in the mental health system generally have expertise in a biopsychosocial approach to the identification, diagnosis, and treatment of psychiatric disorders, some lack similar skills and knowledge about the specific drugs of abuse, the biopsychosocial processes of abuse and addiction, and AOD treatment, recovery, and relapse. Similarly, AOD treatment professionals may have a thorough understanding of AOD abuse treatment but not psychiatric treatment.
The Addiction Treatment System
As with mental health treatment, no single addiction treatment system exists. Rather, there is a collection of different types of services such as social and medical model detoxification programs, short- and long-term treatment programs, methadone detoxification and maintenance programs, long-term therapeutic communities, and self-help adjuncts such as the 12-step programs. These programs can vary greatly with respect to treatment goals and philosophies. For example, abstinence is a prerequisite for entry into some programs, while it is a long-term goal in other programs. Some AOD treatment programs are not abstinence oriented. For example, some methadone maintenance programs have the overt goal of eventual abstinence for all patients, while others promote continued methadone use to encourage psychosocial stabilization.
As with mental health treatment, addiction treatment is provided by a diverse group of practitioners, including physicians, psychiatrists, psychologists, certified addiction counselors, MFCCs, and other therapists, counselors, and recovering paraprofessionals. There can be a wide difference in experience, expertise, and knowledge among these diverse providers. As with mental health treatment, most States have public and private AOD treatment systems.
The strengths of addiction treatment services include the multidisciplinary team approach with a biopsychosocial emphasis, and an understanding of the addictive process combined with knowledge of the drugs of abuse and the 12-step programs. In typical addiction treatment, medications are used to treat the complications of addiction, such as overdose and withdrawal. However, few medications that directly treat or interrupt the addictive process, such as disulfiram and naltrexone, have been identified or regularly used. Maintenance medications such as methadone are crucial for certain patients. However, most addiction treatment professionals attempt to eliminate patients’ use of all drugs.
Similarities of Mental Health and Addiction Treatment Systems
Variety of treatment settings and program types
Public and private settings
Multiple levels of care
Increasing use of case and care management
Value of self-help adjuncts.
Many who work in the addiction treatment field have only a limited understanding of medications used for psychiatric disorders. Historically, some people have mistakenly assumed that all or most psychiatric medications are psychoactive or potentially addictive. Many addiction treatment staff tend to avoid the use of any medication with their patients, probably in reaction to those whose addiction included prescription medications such as diazepam (Valium). Many staff have a lack of training and experience in the use of such medications. In the treatment of dual disorders, a balance must be made between behavioral interventions and the appropriate use of nonaddicting psychiatric medications for those who need them to participate in the recovery process. Withholding medications from such individuals increases their chances of AOD relapse.
An important adjunct to addiction treatment services is the massive system of consumer-developed groups, such as the 12-step program of Alcoholics Anonymous (AA). Participants in AA and other self-help groups (Narcotics Anonymous [NA], Cocaine Anonymous [CA], etc.) can provide needed support and encouragement for patients in treatment. Importantly, these services are widespread nationally and internationally. While self-help programs are not considered treatment per se, they are integral adjuncts to professional treatment services.
However, patients in self-help groups may give others inappropriate advice regarding medication compliance, based on personal experience, fears of medication, or incomplete knowledge about the role of medication in dual disorders. In many urban areas, there are specialized 12-step groups for people with dual disorders. In these so-called “Double Trouble” meetings, medication compliance is a part of “working the program.”
The Medical System
Primary health care providers (physicians and nurses) have historically been the largest single point of contact for patients seeking help with psychiatric and AOD use disorders. Physicians and nurses are uniquely qualified to manage life-threatening crises and to treat medical problems related and unrelated to psychiatric and substance use disorders. And because they are in contact with such large numbers of patients, they have an exceptional opportunity to screen and identify patients with psychiatric and AOD disorders.
However, physicians - especially primary care physicians - are able to devote very little time to each patient. Pressured for time, these physicians may prescribe such psychiatric medications as antidepressants or anxiolytics or medication such as disulfiram or naltrexone as a primary approach, rather than as an adjunctive approach. Indeed, primary care physicians are the largest single prescriber of antianxiety medications. Some of these medications, such as the benzodiazepines, are psychoactive and can be abused.
Also, physicians and nurses have historically been trained to focus on the medical consequences of addiction, such as withdrawal, overdose, or hepatitis, without assessing, treating, or actively referring the individual for treatment of the addiction itself. The role of physicians with regard to addiction is changing through the leadership of national organizations such as the American Society of Addiction Medicine, the American Academy of Psychiatrists on Alcohol and Addiction, and the Association of Medical Education and Research on Substance Abuse. Similar groups exist for nurses and allied health care professionals. Such groups can provide medical professionals with important information and education about the biopsychosocial nature of addiction and treatment, especially regarding patients with dual disorders.
Differing Approaches: Individual Responsibility and Treatment Focus
Traditionally, patients in mental health settings have had the responsibility of getting themselves to treatment services and appointments as a sign of treatment motivation. More recently, and in recognition that many severely mentally ill patients are unwilling or unable to use traditional community-based services, the mental health field has emphasized the role of case management. Case management (also called care management) can help to engage, link, and support patients in needed community services. Case management can help to reduce the negative consequences to the individual from lack of followup and participation in treatment. Without case management, many severely ill patients would decompensate, need to be hospitalized, or become homeless.
The case management model identifies individual limitations, deficits, and strengths and aggressively attempts to provide patients with what they need. When a patient rejects professional assistance, the case manager assumes the responsibility for finding a different way to get the individual to accept assistance. The case manager may minimize the negative consequences to the individual in order to engage or maintain the patient in treatment. This activity might be seen as “enabling” by traditional addiction treatment personnel.
In contrast, the addiction treatment system focuses on individual responsibility, including the responsibility of accepting help. Motivation for recovery is enhanced through confrontation of the adverse consequences of addiction. Further, addiction intervention and treatment involve diminishing the individual’s denial about the presence and severity of the addiction through direct but therapeutic confrontation of examples of addiction-related behaviors. Thus, traditionally, patients in the addiction treatment system who did not want help or could not tolerate confrontation might not get help. Mental health personnel might regard this situation as an abandonment of the most needy. More recently, the addiction treatment system has been developing case management models to better address treatment-resistant patients.
Treatment of patients with dual disorders must blend both mental health and AOD treatment models, with each applied at appropriate times and in appropriate situations according to patients’ needs. There should be a balance between clinician and patient acceptance of responsibility for treatment and recovery from dual disorders.
For example, in AOD treatment, clinical staff and fellow patients often aggressively confront patients who deny that they have an AOD problem or who minimize the severity of their problem. However, treatment of individuals with dual disorders first requires innovative approaches to engage them in treatment as a prerequisite to confrontation. The role of confrontation may need to be substantially modified, particularly in the treatment of disorganized or psychotic patients, who may tolerate confrontation only in later stages of treatment (when their symptoms are stable and they are engaged in the treatment process).
In addiction treatment, the focus is often on the “here and now,” while in mental health treatment, the focus is often on past developmental issues. Mental health practitioners may identify AOD abuse as a symptom of a prior trauma rather than an illness in its own right. The focus of treatment may be on the developmental issues, with the assumption that the AOD use disorder will improve automatically once these issues are treated. Inadvertently, the mental health therapist can enable AOD use to continue.
The Role of Abstinence
Within parts of the addiction treatment system, abstinence from psychoactive drugs is a precondition to participate in treatment. For the more severely ill patients with dual disorders (such as patients with schizophrenia), abstinence from AODs is often considered a goal, possibly a long-term goal, similar to the approach at some methadone maintenance programs. On the other hand, treatment of less severe dual psychiatric conditions, such as depression or panic disorder, should require AOD abstinence, since AOD use compromises both diagnosis and treatment.
For some patients with dual disorders, requiring abstinence as a condition of entering treatment may hinder or discourage engagement in the treatment process. For these patients, abstinence may be redefined as a goal, with encouragement provided for incremental steps in the reduction of amount and frequency of drug use. For example, patients who experience homelessness and housing instability likely do not live in drug-free environments. For such patients, it may be unrealistic to mandate abstinence as a requirement for treatment.
Treatment Models: Sequential, Parallel, Or Integrated
As the mental health and AOD abuse treatment fields have become increasingly aware of the existence of patients with dual disorders, various attempts have been made to adapt treatment to the special needs of these patients. These attempts have reflected philosophical differences about the nature of dual disorders, as well as differing opinions regarding the best way to treat them. These attempts also reflect the limitations of available resources, as well as differences in treatment responses for different types and severities of dual disorders. Three approaches have been taken to treatment.
The first and historically most common model of dual disorder treatment is sequential treatment. In this model of treatment, the patient is treated by one system (addiction or mental health) and then by the other. Indeed, some clinicians believe that addiction treatment must always be initiated first, and that the individual must be in a stage of abstinent recovery from addiction before treatment for the psychiatric disorder can begin. On the other hand, other clinicians believe that treatment for the psychiatric disorder should begin prior to the initiation of abstinence and addiction treatment. Still other clinicians believe that symptom severity at the time of entry to treatment should dictate whether the individual is treated in a mental health setting or an addiction treatment setting or that the disorder that emerged first should be treated first.
The term sequential treatment describes the serial or nonsimultaneous participation in both mental health and addiction treatment settings. For example, a person with dual disorders may receive treatment at a community mental health center program during occasional periods of depression and attend a local AOD treatment program following infrequent alcoholic binges. Systems that have developed serial treatment approaches generally incorporate one of the above orientations toward the treatment of patients with dual disorders.
A related approach involves parallel treatment: the simultaneous involvement of the patient in both mental health and addiction treatment settings. For example, an individual may participate in AOD education and drug refusal classes at an addiction treatment program, participate in a 12-step group such as AA, and attend group therapy and medication education classes at a mental health center. Both parallel and sequential treatment involve the utilization of existing treatment programs and settings. Thus, mental health treatment is provided by mental health clinicians, and addiction treatment is provided by addiction treatment clinicians. Coordination between settings is quite variable.
A third model, called integrated treatment, is an approach that combines elements of both mental health and addiction treatment into a unified and comprehensive treatment program for patients with dual disorders. Ideally, integrated treatment involves clinicians cross-trained in both mental health and addiction, as well as a unified case management approach, making it possible to monitor and treat patients through various psychiatric and AOD crises.
There are advantages and disadvantages in sequential, parallel, and integrated treatment approaches. Differences in dual disorder combinations, symptom severity, and degree of impairment greatly affect the appropriateness of a treatment model for a specific individual. For example, sequential and parallel treatment may be most appropriate for patients who have a very severe problem with one disorder, but a mild problem with the other. However, patients with dual disorders who obtain treatment from two separate systems frequently receive conflicting therapeutic messages; in addition, financial coverage and even confidentiality laws vary between the two systems.
In contrast, integrated treatment places the burden of treatment continuity on a case manager who is expert in both psychiatric and AOD use disorders. Further, integrated treatment involves simultaneous treatment of both disorders in a setting designed to accommodate both problems.
Critical Treatment Issues For Dual Disorders
Mental health and addiction treatment programs that are being designed to accommodate patients with dual disorders should be modified to address the specific needs of these patients. Although there are different dual disorder treatment models, all such programs must address several key issues that are critical for successful treatment. These issues include: 1) treatment engagement, 2) treatment continuity and comprehensiveness, 3) treatment
In general, treatment engagement refers to the process of initiating and sustaining the patient’s participation in the ongoing treatment process. Engagement can involve such enticements as providing help with the procurement of social services, such as food, shelter, and medical services. Engagement can also involve removing barriers to treatment and making treatment more accessible and acceptable, for example, by providing day and evening treatment services. Engagement can be enhanced by providing adjunctive services that may appear to be indirectly related to the disorders, such as child care services, job skills counseling, and recreational activities. It may also be coercive, such as through involuntary commitment or a designated payee.
Engagement begins with efforts that are designed to enlist people into treatment, but it is a long-term process with the goals of keeping patients in treatment and helping them manage ongoing problems and crises. Essential to the engagement process is: 1) a personalized relationship with the individual, 2) over an extended period of time, with 3) a focus on the stated needs of the individual.
For patients with dual disorders, engagement in the treatment process is essential, although the techniques used will depend upon the nature, severity, and disability caused by an individual’s dual disorders. An employed person with panic disorder and episodic alcohol abuse will require a different type of engagement than a homeless person with schizophrenia and polysubstance dependence. With respect to severe conditions such as psychosis and violent behaviors, therapeutic coercive engagement techniques may include involuntary detoxification, involuntary psychiatric treatment, or court-mandated acute treatment.
To treat patients with dual disorders, it is critical to develop continuity between treatment programs and treatment components, as well as treatment continuity over time. In practice, many patients participate in treatment at different sites. Even in integrated treatment programs, many patients require different treatment services during different phases of treatment. For this reason, treatment should include an integrated dual disorder case management program, which can be located within a mental health setting, an addiction treatment setting, or a collaborative program.
An overall system for treating dual disorders includes mental health and addiction treatment programs, as well as collaborative integrated programs. Programs should be designed to: 1) engage clients, 2) accommodate various levels of severity and disability, 3) accommodate various levels of motivation and compliance, and 4) accommodate patients in different phases of treatment. There should be access to abstinence-mandated programs and abstinence-oriented programs, as well as to drug maintenance programs. Different levels of care, ranging from more to less intense treatment, should be available.
Phases of Treatment
In general, the medical term acute describes phenomena that begin quickly and require rapid response. Acute problems are contrasted with chronic problems. Most commonly, acute stabilization of patients with dual disorders refers to the management of physical, psychiatric, or drug toxicity crises. These include injury, illness, AOD-induced toxic or withdrawal states, and behavior that is suicidal, violent, impulsive, or psychotic.
The acute stabilization of AOD use disorders typically begins with detoxification, such as inpatient detoxification for patients with significant withdrawal or outpatient detoxification for mild to moderate withdrawal, as well as nonmedical withdrawal, such as occurs in social-model detoxification programs. Also, initiation of methadone maintenance can provide outpatient acute stabilization for patients addicted to opioids.
Acute stabilization of psychiatric symptoms more frequently occurs within a mental health or emergency medical setting, but involves a range of treatment intensity. Patients with severe symptoms, especially psychotic, violent, or impulsive behaviors, usually require acute psychiatric inpatient treatment and psychiatric medications, while patients with less severe symptoms can be treated in outpatient or day treatment settings.
Dual disorder programs that provide stabilization to patients with acute needs should have the capability to:
- Identify medical, psychiatric, and AOD use disorders
- Treat a range of illness severity
- Provide drug detoxification, psychiatric medications, and other biopsychosocial levels of treatment
- Provide a range of intensities of service
These programs should be capable of promoting the patient’s engagement with the treatment system. They should be able to aggressively provide linkages to other programs that will provide ongoing treatment and engagement.
The medical term subacute describes the status of a medical disorder at points between the acute condition and either resolution or chronic state. The subacute phase of a medical problem occurs as the acute course of the problem begins to diminish, or when symptoms emerge or reemerge but are not yet severe enough to be described as acute.
For example, patients recently detoxified from AODs frequently experience subacute symptoms such as insomnia and anxiety that may linger for a few days or weeks. On the other hand, recently detoxified patients with dual disorders may experience subacute symptoms of insomnia and anxiety either as subacute withdrawal symptoms or as a prelude to relapse with depression. Although the subacute phase is not generally regarded as a period of crisis, ignoring these symptoms and failing to assess and treat them may lead to symptom escalation, decompensation, and relapse.
As AOD-induced toxic or withdrawal symptoms resolve, constant reassessment and rediagnosis is required. During this phase, a psychoeducational and behavioral approach should be used to educate patients about their disorders and symptomatology. During this phase, treatment providers should provide assessment and planning for dealing with long-term issues such as housing, long-term treatment, and financial stability.
The treatment settings for long-term treatment, rehabilitation, and recovery from dual disorders include outpatient, day treatment, and residential settings. Ideally, treatment intensity is dictated by disorder severity and motivation for treatment, as well as by personal and local treatment resources. In more severe conditions, ongoing dual disorder case management is essential.
With regard to the initiation and maintenance of sobriety in patients with dual disorders, another way of looking at acute, subacute, and long-term phases involves a four-step approach that leads to abstinence. This approach is particularly important for patients with severe psychiatric problems and an AOD use disorder (Minkoff and Drake, 1991; Ries, 1993a).
Individual case management. Individual case management provides an initial introduction to treatment goals and concepts and may provide assistance with regard to crises, housing, and entitlements. An individual treatment plan is developed.
Persuasion groups. Patients who display strong denial about their AOD use disorder and lack motivation can attend persuasion groups, which provide basic AOD education and treatment engagement. Premature, potent, and direct confrontation and an insistence on abstinence should be avoided since these approaches may prompt more fragile patients to leave treatment.
Active treatment groups. Active treatment groups consist of patients who have accepted the goal of abstinence and are relatively mentally stable. These groups use supervised peer confrontation and a psychoeducational-behavioral approach to AOD abuse.
Abstinence support groups. Finally, abstinence support groups consist of patients who are essentially committed to abstinence and are relatively stable mentally, who require ongoing education and support for sobriety and the development of relapse prevention skills.
Psychiatric and AOD abuse treatment issues are woven into the groups in such a way that concrete issues (such as medication compliance) are addressed in persuasion groups, while abstract concepts (such as self-image) are addressed in active treatment or abstinence support groups. Some patients - such as severely psychotic patients - may not be able to advance beyond persuasion groups or active treatment groups.
Diseases and Conditions Center
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