This column attempts to translate clinical research into something that can be used quickly in actual treatment. No single method is going to work with all people, all the time. However, research, above all other forms of evidence, will point you in a better direction.

Please note that the sun (¤) symbol will be your guide to practical interventions. Finally, we try to end each column with an experiment you may want to conduct. For this article, I'll address one of the biggest problems in our field - dual disorders.

A quick overview
Figures vary, but best estimates are that about half of the individuals who have an addiction problem also have a significant level of psychiatric problems (Rosenthal & Westreich, 1999). This combination of problems is generally referred to as dual or co-occurring disorders. The phrase dual disorders has a number of names, for example, mentally ill chemical abusers (MICA), chemically abusing mentally ill (CAMI), mentally ill substance abuser (MISA), and the non-substance-related (NSR) mental disorders (Rosenthal & Westreich, 1999). We won't get into which is the best or proper phrase. For our purposes, the term dual disorders will do just fine.

Research-based treatment suggestions
Despite the frustration and seemingly chronic non-response to strategies we implement with such clients, a few practical elements have emerged from the literature. In this column we will cover ideas you can use at the personal contact level. We will address research aimed at the program level in another column.
Most information for this column comes from a fellow named Drake. He has established a fine research reputation, and it is a name to know when you scan the literature. In terms of the personal contact interventions, here are a few good ideas (Drake et al., 1998):

1. ¤ For the substance abuse counselor who thinks confrontation is the treatment of choice to break through denial with clients with dual disorder - research indicates otherwise. The data clearly indicates confronting a client with a dual diagnosis is not a good idea. Confrontation is often accompanied by anxiety ? not the feeling a counselor wants to increase. Research suggests decreasing the anxiety, and the anxiety reduction procedure with this population needs to be individualized, as does all treatment of clients with dual disorders (Rosenthal & Westreich, 1999). Therefore, you need to experiment with stress management and relaxation strategies for each client. Positive results will be evident when clients actually use the strategies that work best for them. You know you're on the right track when they report a drop in anxiety.

2. ¤ Research suggests clinical work with a client with dual diagnosis needs to be established on a basis of trust and understanding. Confrontation and criticism are not treatments of choice. Trust and understanding are key elements in empathy, which has always been considered one of the most important features of counseling. It continues to receive strong research support as a critical treatment component for better outcomes (Hubble et al., 1999). The problem is that empathy is complex, so for our purposes, let's concentrate on the basics of trust, listening, and understanding. Empathy is getting as close as you can to knowing how a client thinks and feels. Knowing how a client thinks and feels in no way enables. Furthermore, empathy does not mean tagging a client with some pop psychology or recent workshop term. After a client discloses a litany of feelings and thoughts, the last thing you want to do is lean forward and say, "Oh, you're co-dependent or in the pre-contemplation stage of change." These kinds of clinical responses just don't elicit empathy. By saying such words to a client following a disclosure of emotion you, in effect, have said, "I didn't listen." Clients will pick up on that, and some may begin to distance themselves from you. For the most part, clients want to be heard - so listen.

3. ¤ The research data suggests that the emphasis with clients with dual disorders needs to be on reducing the harm from substance abuse. Expecting or demanding immediate abstinence does not look like the way to go early on in treatment. Now, I know that the idea of expecting anything other than abstinence up front is a tough idea for many addiction counselors. But, consider this only as a "starting point" philosophy, not a "forever" philosophy. Any success with someone with severe mental health and substance abuse problems needs to be seen as productive, even if it takes place in very small steps. So, if a clinically depressed client reports drinking a few less beers over the weekend, take that as positive movement - particularly with this population.

4. ¤ If you want to obtain better results with clients with a dual disorder, maintain flexible and familiar office hours. The research does not support fixed office hours. The need to talk or resolve a crisis knows no schedule with this population. This certainly requires more work and effort for you and your program, but you will get better results.

5. ¤ Mandating attendance of 12-step groups is not supported by the research. Better results will come if the client chooses the 12-step group. Certainly, recommendations for such support groups are important, but mandating is not recommended.

6. ¤ The data is improving regarding the types of treatments that do and do not work with the dually disordered. The evidence is pretty clear. Confrontation and the front-loaded or one-size-fits-all types of programs do not work very well. If you are applying these to the dually disordered, you may want to consider discontinuing them. The data supported directions include staged interventions and motivational counseling. Staged interventions follow the stages of change theories of Prochaska and DiClemente (1992). Those stages are: precontemplation, contemplation, preparation, action, and maintenance. Motivational counseling is that form of therapy developed by Bill Miller (Miller & Rollnick, 2002).

7. ¤ This item has a strong research base: The use of medications, in those cases where they are indicated, will have a positive effect on clinical outcomes. Standing on a position that all medications are to be contraindicated is not such a good idea. Again, some in the field find the administration of medications to clients with an addiction problem unpalatable. Yet, if you work with dual disordered clients, sooner or later you are going to have to consider, if not encourage, the appropriate and monitored use of prescription medications.
8. ¤ This last item will come as no surprise to the clinicians who work with the dual disordered. The recovery process is going to take a protracted time. That means you as the primary clinician are in this for the long haul. Recall that two years is considered a reasonable time for recovery to take hold. Shy away from thinking short-term treatment is going to work for much of this group. Drake also indicates that it is going to take about two years for some sort of stable sobriety to establish itself (Drake et al., 1993).

Michael J. Taleff, PhD, CSAC, MAC, is the Coordinator of the Center for Substance Abuse for the University of Hawai'i at Manoa.

References
Drake, R.E., Mercer-McFadden, C., Mueser, T., McHugo, G.J. & Bond, G. (1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24, (4), 589-608.
Drake,R.E., McHugo, G.J., & Norrsby, D.L. (1993). Treatment of alcoholism among schizophrenia outpatients: 4-year outcomes. American Journal of Psychiatry, 150, 328-329.
Hubble, M., Duncan, B.L. & Miller, S.D. (1999). The heart and soul of change: What works in therapy. American Psychological Association: Washington, D.C.
Miller, W.R. & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd Ed.). Guilford: New York, NY.
Prochaska, J.O., DiClemente, C.C., & Norcross, J.C. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102-1114.
Rosenthal, R.N, & Westreich, L. (1999). Treatment of persons with dual disorders of substance abuse and other psychological problems. In B. S. McCrady & E.E. Epstein (Eds.), Addictions: A comprehensive textbook (pp. 439-476). Oxford University Press: New York, NY.

No one has commented on this article.

Please keep your comments brief and on topic, and remember that this is not a discussion thread.
Name :
Comment(s) :

J! Reactions 1.09.00 • Professional Site License
Copyright © 2006 S. A. DeCaro

---