People with serious persistent mental illness and addiction often lack the ego strength and coping skills necessary to put a recovery program into action. This necessitates modifications in the treatment approach.

An important principle in the management of a dually diagnosed individual is that treatment for both conditions must receive equal emphasis and attention. Ideal programming integrates mental health care with interventions for the addiction; the patient should be receiving everything needed to treat both the psychiatric condition and the addiction.

A successful dual diagnosis program is staffed by clinicians who have had training and experience in addiction treatment as well as in the treatment of chronic mental illness. A team of professionals from different disciplines meet to discuss the needs of the client and provide a spectrum of interventions.

Intensive case management has been useful in keeping people with mental illness and addiction engaged in treatment.

In this model, clients are assigned to a case manager who makes frequent contact, often going into the community to visit the client’s home. The case manager makes sure that the client has medical and psychiatric follow-up and is enrolled in specific programming to address both problems. The case manager does not provide therapy but does offer interpersonal contact and support that would otherwise be lacking for a person with impaired social functioning. Over time, a trusting relationship develops which allows the case manager to be more effective in helping the client make better choices about using alcohol or drugs.

Clinic-based groups that focus on addiction and mental illness are an important feature of dual diagnosis programming.

These groups are led by a therapist, and combine education about substance abuse with an opportunity for structured interaction. Motivational group therapy is a nondirective approach that helps clients examine their behaviors without fearing judgment or criticism. In such a group setting people with different degrees of success with sobriety can provide useful feedback and role modeling.

Sometimes hospitalization or residential treatment is needed. Residential programs for the dually diagnosed utilize a team approach. Long-term stays are often needed so that problems with both the mental illness and the addiction can be fully addressed. If the mental illness is active at the time of admission, it may be a while before the person is able to look at the addiction. Nonetheless, interventions aimed at increasing awareness of addiction and its consequences should occur early in the course of hospitalization, in a supportive and nonthreatening manner.

People with serious mental illness often do poorly in AA or other 12-step groups. Since they are deficient in social functioning, they may act inappropriately or misinterpret the statements and behaviors of others. Occasionally the content of the 12 steps triggers religious delusions. The emphasis on abstinence from all mood-altering substances may also be misinterpreted as permission to stop taking needed medication.

Dual Recovery Anonymous groups are available in some locations. These are 12-step groups composed of people with both serious mental illness and addiction. Sometimes they are sponsored by a mental health clinic and are facilitated by a therapist. The principles in the 12 steps are used not only to deal with the addiction but also to promote acceptance of the chronic mental illness and personal responsibility for recovery from both conditions.

As treatments improve for serious persistent mental illness, people with these disorders suffer fewer residual symptoms during periods of remission and fewer side effects from medication. But there remain a large number of people with addiction and mental illness who are alienated from the system of care. Many of them are homeless and destitute. Assertive outreach programs send workers into the community, where they attempt to make consistent contact with these people in order to engage them in treatment and to provide needed services.

Housing is a big problem for the dually diagnosed. Many receive disability payments and are trying to live on meager fixed incomes. Because of the behavior problems associated with addiction, some are evicted from government-supported housing and shelters. Some communities provide supervised group homes for the dually diagnosed where treatment can be monitored and services provided for both kinds of problems.

The challenge to clinicians who treat the dually diagnosed is the diversity of the problems that clients encounter. The severity of the mental illness and of the addiction can range from mild to severe. The majority of people who have addiction and another psychiatric diagnosis are able to participate fully in traditional alcohol and drug programming with only minor modification. But for those with severe mental illness as well as addiction, a spectrum of services is needed to cover all aspects of the person’s life.

Outcome measures are clear, and this is the good news.

People with severe mental illness and addiction make steady progress in these programs, achieving both recovery from the addiction and more stable remission from the mental illness.

Elizabeth Connell Henderson, M.D.

 

Glossary

Appendix A: Regulation of Addictive Substances

Appendix B: Sources of Additional Information