Clients who have both a mental illness and a substance abuse problem are particularly challenging to personnel in treatment programs. Estimates of the incidence of co-occurrence of mental illness in substance abuse vary, depending on the source, how the terms are defined, and the point the writer is trying to make. Using broad definitions of mental illness and substance abuse disorder, one can assume that persons who have only one of the disorders are the exception rather than the rule.

There is a synergistic interaction between mental disorders and substance abuse. The mental disorder increases the tendency to use drugs, and the drug use increases the severity of the mental disorder. Therefore, it is essential that both disorders be addressed in treatment, since the untreated one will trigger a relapse in the treated one.

Persons with Antisocial Personality Disorder (the mental disorder that commonly accompanies substance abuse disorders) more often than not engage in alcohol and drug abuse as a part of the larger picture of their "acting out" behavior and reckless lifestyle. Drug use can provide temporary escape from the difficulties the person's behavior has brought on, but, in turn, increases the acting out behavior, so that a vicious cycle develops. It is generally impossible for the clinician to determine in early contacts with the Antisocial Personality Disordered (APD) client whether the personality disorder is freestanding, i.e., independent of the substance abuse, or whether it is a behavioral adaptation to the demands of chemical dependency.

Transtheoretical issues

In Dual Diagnosis: An Integrated Approach to Treatment, Ara Lewellen, Marjie Barrett and I (2001) relied heavily on the Transtheoretical Model developed by Prochaska and DiClemente (1986). There are several aspects of this model that are particularly relevant to dually disordered clients.

First is the issue of readiness to change. Persons can be unaware of the nature of their problem, or even that they have a problem. Addiction treatment programs call this "denial," which has a pejorative ring to it. Prochaska and DiClemente call it the "precontemplative stage." The second level of readiness is the "contemplative" stage in which the client is considering whether or not they have a substance abuse (or mental health) problem. They will be gathering evidence for and against the argument that they have a problem. Heavy-handed accusations, blaming, or labeling during this stage are likely to cause the client to retreat to the psychological safety of the precontemplative stage again. After an often lengthy process of deliberation, the client may decide to undertake change. This may involve self-help methods (such as trying to quit cold turkey on their own), attending a group (such as AA or NA), getting religion, or entering a treatment program. Several efforts are usually required before success is achieved, and even then it may be short-lived. The last stage of readiness is "maintenance," the vigilant follow-through required to prevent relapse.

We believe that many, if not most, treatment "failures" occur because the "program" operates under the assumption that the client is ready to institute major changes when the client is in the precontemplative or contemplative stage of readiness for change. Even though going through the treatment program may move the client from the precontemplative stage into the contemplative, the treatment is considered a failure because the client is not yet sober or drug free, the standard measure of treatment success.

Another dimension of the Transtheoretical Model that fits our experience is the identification of the elements in treatment that have been shown to contribute to positive change, the processes of change (Prochaska & DiClemente, 1986). These ten processes cover a broad range of techniques, including behavioral (stimulus control, counter-conditioning, and contingency management), "insight" (consciousness raising, self-liberation, self-reevaluation, and environmental reevaluation), relationship-based (dramatic relief and helping relationship) and socio-environmental (social liberation).

Prochaska and DiClemente applied the transtheoretical model to treatment of addictive disorders, but it is equally applicable to psychiatric disorders. In the case of the dually disordered client, he or she may be in the active stage of readiness to change in relation to the mental disorder, but still in the precontemplative stage regarding substance abuse, or vice versa. Since the appropriateness of specific processes of change is dependent largely on the readiness level, the professional may be using consciousness raising with the client to increase his/her awareness of their drug problem, while applying counter-conditioning methods to change behaviors that represent acting out symptoms of the mental illness.

Applications to clients with APD

The focus of this article is treatment of those persons abusing substances that have APD. Unlike clients with disorders such as schizophrenia, bipolar disorder, or major depression, they do not have blatant symptoms that might elicit sympathy from staff. They appear to be "normal," even competent and self-assured, and consequently often are viewed just as difficult clients. And indeed, they are difficult, as they tend not to follow treatment regimens, to have serious interpersonal problems with staff and other clients, and to take far more than their fair share of time and attention from staff.

Antisocial Personality Disorders are, by definition, resistant to change. The DSM-IV-TR defines APD as "a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood" (APA, 2000). Because these disorders are so resistant to change, treatment personnel do not get the reinforcing feedback they seek from these clients' rapid recovery. APD is characterized by erratic, "acting out," self-serving behavior that can be highly manipulative, and which triggers hostile responses in therapists who are not sophisticated or self-aware. Similarly, when they are not in compliance with treatment recommendations, they may be seen as deliberately resistant, raising counter-transference issues with treatment personnel. Substance abuse is a result of both the unconscious psychic pain and the general impulsivity of the APD client. It lowers the already weak impulse control and inhibitions of the client, exaggerating the inherent tendency to act out emotions in irresponsible and destructive ways, including further substance abuse.

Assessment considerations

APD clients are recognized primarily by their pattern of acting out behavior and poor interpersonal relationships. Since they also often have problems with additional disorders such as anxiety and depression, assessment must be broad and multifaceted. Three sources of information are valuable in assessment: 1) psychological testing (including self-report inventories such as the Personality Disorder Questionnaire, Revised), 2) the clinical interview, and 3) collateral contacts. While the use of psychological tests in identifying personality disorders is desirable, the skillful clinical interview is essential.

The use of collateral sources of information such as family members greatly increases the speed and accuracy of assessments. In addition to the tendency of substance abusers to understate the extent of their substance use, clients with APD often have cognitive distortions, are generally unaware of the extent to which their behavior disrupts the lives of those around them, and therefore understate their problems. These three sources of information; standardized measurement instruments, the clinical interview with the client, and interviews with collaterals, in combination, can provide sufficient data for beginning treatment. Once the presence of APD order is established, the clinician needs to assess the client's aptitude for change, their ability to experience and be aware of a wide range of feelings; the ability to see the connection between their behavior and its consequences; the ability to relate to the therapist; their reaction to stress within the interview; the extent and consequences of substance abuse in their life; and the source and severity of their subjective distress, i.e., level of motivation. The APD client is often most vulnerable and least defended during the first interview, making this the ideal time to get a clear picture of the client's personality disorder (Magnavita, 1997).

Treatment goals

It is important to set goals that are realistic in view of the high level of defensiveness inherent in the APD. Kantor (1992) speaks of three ranges on the continuum of personality disorderedness: the normal, the semi-normal, and the abnormal.

The normal may antagonize others through inconsiderate behaviors, but is not perceived as pathological. The semi-normal act out in order to deflect anxiety, but their symptoms are less driven and more intermittent than those of the abnormal. Symptomatic behavior of the abnormal is more pervasive, chronic, unremitting, and troublesome. Realism in goal setting may mean assisting the client to move from the "abnormal" range into the "semi-normal" as opposed to expectations that the client will become "normal." Sperry (1995) refers to this movement as being from "personality disordered" functioning to a "personality style" functioning. It is unlikely that the client will ever lose the flavor of the disorder, but its severity can be reduced so that the client can function more acceptably in the social world. Any reduction in the use of alcohol and other drugs will move the client away from the "abnormal" extreme of the continuum. Lessening the client's defensiveness and teaching new social skills will further move the client toward a more pro-social adjustment. The general professional pessimism about treatment of persons with personality disorders is less justified if one accepts goals that are less than "total cure."

Readiness for change

The first major obstacle in treatment of the APD client is the apparent low level of motivation for change. Motivation can be conceptualized as awareness of discomfort with one's present condition and a hope that it can be improved through treatment. The motivating discomfort generally comes from an external source, such as trouble with the law, threats to marital status, or difficulty maintaining employment.

APD substance abusers seldom seek therapy for its own sake. They are in the "precontemplative stage of change," but also in a crisis that involves unpleasant consequences of their own behavior. Since they see the source of the problem as someone other than themselves, they are seeking symptomatic relief only. The temporary disequilibrium caused by the crisis provides a unique window of opportunity for therapeutic intervention. The combination of discomfort and the hope that the therapist can do something to stop it provide an opportunity for the therapist to get the "foot in the door" in intervention. This population tends to not follow through on a long-term basis with treatment, so it is imperative that the clinician "hook" the client's interest quickly. This improves the chances for staying in treatment until positive change can provide motivation for further follow through. Even very short-term treatment can disrupt the client's dysfunctional reactive behavior enough to bring modest long-term improvement.

The helping relationship

The helping relationship is the key link between the client's discomfort with the status quo and engagement in the treatment process. It should be collaborative in nature, and based on the clinician's understanding of the client's attachment and control issues. The steady, non-judgmental, empathic, but reality-based relationship between the clinician and APD client lessens the client's anxiety and impulsiveness. Often the assessment interview has begun a rapport between the client and the therapist, based on the clinician's understanding, acceptance, and focused attention to the client.

The client is further engaged by the clinician's empathic responses to client complaints about the state of his/her life at this crisis point. This approach meets the narcissistic demands of APD clients, thereby providing a psychologically rewarding relationship that increases their readiness for change.

Consciousness-raising

Within this relationship, the clinician can carefully confront the client with the connection between the client's dilemma and his/her specific behaviors. This confrontation must be clearly prioritized and provided in small enough steps that, alternated with supportive empathy, it does not antagonize the client enough to cause a retreat from treatment. Since the therapeutic engagement is tentative, each contact with the client must be conducted as if it may be the last one. These clients are generally less threatened by cognitive approaches than emotional ones, so initial confrontations should be presented in a non-emotional factual style, such as "Have you noticed that each time you have gotten arrested you were under the influence of drugs or alcohol? Are you perhaps not as much in control of yourself when on drugs?"

Not feeling attacked or crowded, the client is more likely to begin to make cognitive connections that can lead to behavioral change, thus enhancing the client's sense of being in control and minimizing resistance. Each time resistance becomes apparent, more empathic support is needed. In residential settings or when group sessions augment individual treatment, the APD client will usually receive more aggressive confrontation from other clients, allowing the clinician to provide a more supportive relationship in which the client can process the negative group feedback in a non-threatening setting, thereby enabling him/her to accept it in manageable doses.

This is obviously a slow process, with a constant threat of disengagement. The client should be asked to contract for a specific number of sessions (even as few as four) in order to reduce the likelihood of abrupt withdrawal from treatment. It is important to deal early on with issues that are most likely to bring meaningful behavioral change. The connection of substance abuse to the client's situational problems is most central, and therefore should be brought to the fore early in treatment. Any degree of success in reducing the client's drug abuse will improve impulse control and the ability to make more deliberate choices, thereby raising the client's hope for further improvement in handling problems in living.

Nevertheless, there is likely to be vacillation from stage to stage, maintaining a highly tentative commitment to the treatment process. Clients having APD as well as substance abuse problems stir powerful counter-transference feelings in treatment staff.

The clinician may experience rescue fantasies, defensiveness against the client's hostility, power struggles against the manipulations or threats of the antisocial client, or anger at the client's lack of compliance with treatment expectations. Each of these reactions will interfere with therapeutic objectivity and the ability of the therapist to remain "stable, persistent, and thoroughly incorruptible" (Sperry, 1995).

Cognitive-behavioral dimensions of treatment

Following the development and maximization of motivation for change, and the establishment of a meaningful treatment relationship that gives leverage in the change effort, the application of cognitive and behavioral methods is used to bring about change.

Generally, persons with APD have little understanding of the connection between their thoughts and behavior, and between their behavior and its social and interpersonal consequences. Nevertheless, these non-insightful clients are more amenable to cognitive channels of feedback than affective ones, and behavioral consequences that are reinforced by intellectual (cognitive) explanations (confrontations) make an impact on the client.

Once the client sees the connection between substance use and acting out behavior with its negative consequences, he/she can be engaged in a joint effort at identifying situations, thoughts, or feelings that tend to trigger substance use. Collaborative "brainstorming" can then produce strategies for avoiding the potential triggers (stimulus control) or substituting less destructive responses to the triggers (counterconditioning). It is important to: 1) keep the focus on concrete benefits to the client that will result from changes in behavior, and 2) keep reminding the client of the strategies which they have developed, since new behavioral and cognitive patterns must become "second nature" to these impulsive clients.

Progress will be slow and old behavioral patterns will re-emerge from time to time, in which instances the client should have to experience again the negative consequences inherent in relapse behavior. Positive change will be self-rewarding through the lessened trouble with the social environment.

One dynamic underlying clients' "denial" of the extent of their problems is anxiety about their ability to cope with life without the comfort, excitement, or escape they receive from substance abuse. New coping strategies can be taught. These might include techniques of anger control, non-destructive ways of experiencing excitement, and non-antagonistic negotiation skills. Psychoeducation has proven useful in work with APD substance abusers. The impersonal nature of the didactic presentation allows clients to learn about themselves without having to "admit" or deny the problem. Additionally, psychoeducation groups for family members give them understanding of the nature of the clients' problems, teach them how to avoid being used, and give them encouragement to provide logical and natural consequences when destructive behavior occurs. This will lead to appropriate contingency management, i.e., replacing the "pay-off" of acting out behavior with unpleasant consequences.

Relapse prevention

Insufficient attention to post-treatment community living is a major cause of relapse in APD clients. Social skills initially taught during the action stage of treatment must be generalized to interpersonal interactions with family, peers, employers, and other persons in the client's natural community networks. Reinforcement of stimulus control skills is essential, i.e., the ability to avoid situations that present temptations to use drugs or act out again and the ability to refuse involvement with substance use or destructive behavior when in high-risk situations. It is often helpful to use the leverage of possible criminal justice system involvement or hospitalization to provide the motivation for post-discharge follow-through with APD clients.

Support groups

Self-help groups such as AA and NA are generally recommended for persons with co-existing APD and substance abuse disorders. These clients typically resent referrals to the group. However, if their situational crisis is bad enough, they may participate. They are put at ease by the atmosphere of non-judgmental acceptance in the group meetings. Although they often have a sense of alienation from others, they can identify with other group members who are struggling with impulse control issues and histories of difficulties with family, peers, and the authorities. They can learn from the modeling of more senior members and begin to experience vicarious dramatic relief by listening to the stories of others. Further, the structure of the 12-step program provides a systematic focus for self-improvement for the motivated client. Unlike many persons with whom they have been associated, the 12-step group does not give up on them.

The behavioral traits characterizing the APD client are often found in substance abusers that had no pre-morbid mental disorder, so the person with a personality disorder does not seem markedly different from many other members of the group. Interpersonal problems that typify these clients' relationships are diluted in the group setting. The member with a personality disorder may "con" his or her sponsor or another group member from time to time, but successful manipulation is usually short-lived because the members have "seen it all" in themselves and others.

The substance abuser with APD can improve with treatment, though "complete" recovery is unlikely. Treatment should include development of a structure that contains the client's acting-out behavior enough to engage in cognitive-behavioral substance abuse treatment, with abstinence as a long-term goal. The therapeutic bond may be developed with relative ease through addressing the client's narcissistic need for empathy, but is difficult to sustain through periods of confrontation. Tolerance for both repeated relationship testing and numerous relapses are needed. A careful alternating of empathy and confrontation may result in sufficient time in treatment to make a significant difference in the client's social functioning.

Ted Watkins, DSW, LMSW-ACP, has worked in the areas of substance abuse and mental health for almost four decades. A clinician for many years in a variety of settings in Louisiana, Pennsylvania, and Texas, he is now Director of the BSW Program at Southwest Texas State University, where he trains social workers for practice with dually diagnosed clients. His books, Mental Health Policy and Practice Today (with James Callicutt), and Dual Diagnosis: An Integrated Approach to Treatment (with Ara Lewellen and Marjie Barrett), both deal with issues of dual diagnosis. His current project is collaborating with colleagues on a book relating youth violence to mental health and substance abuse issues. He can be reached via e-mail at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
    American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders, Fourth edition, Text revision (DSM-IV-TR). Washington, D.C.
    Kantor, M. (1992). Diagnosis and treatment of the personality disorder. St. Louis, MO: Ishiyaku EuroAmerica.
    Magnavita, J. J. (1997). Restructuring personality disorders: A short-term dynamic approach. NY: Guilford.
    Prochaska, J. O. & DiClemente, C. C. (1986). Toward a comprehensive model of change. In W. R. Miller & N. Heather (Eds.). Treating addictive behaviors: Processes of change (pp. 3-27). NY: Plenum.
    Ryglewicz, H. & Pepper, B. (1992). The dual disorder client: Mental disorder and substance use. In S. Cooper & T. H. Lentner (Eds.), Innovations in community mental health (pp. 270-290). Sarasota, FL: Professional Resource Press.
    Sperry, L. (1995). Handbook of diagnosis and treatment of the DSM-IV personality disorders. NY: Brunner/Mazel.
    Watkins, T., Lewellen, A., & Barrett, M. (2001). Dual diagnosis: An integrated approach to treatment. Thousand Oaks, CA: Sage.

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Holly A Harwayne   |66.234.197.xxx |2008-03-02 10:34:42 I'm assessing the efficacy of a counseling practice that serves clients who are in the precontemplative or contemplative stage of change. I found solid information to support the concept in this article. Reply 0   0

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