Download Diagnostic Criteria for Schizophrenia

Integrated Treatment for
Dual Disorders
Kim T. Mueser, Ph.D.
Dartmouth Medical School
Dartmouth Psychiatric Research Center
[email protected]
Any Substance Use Disorder
Prevalence % of Substance Use
Disorder
60
50
40
30
20
10
0
Gen.Pop
Schiz
BPD
MD
OCD
Phobia
PD
Rates of Lifetime Substance Use Disorder (SUD) among
Recently Admitted Psychiatric Inpatients (N = 325)
(Mueser et al., 2000)
% of Clients with SUD
100
75
50
25
0
Schizophrenia
Schizoaffective Disorder
Bipolar Disorder
Major Depress ion
Factors Influencing Prevalence
of Substance Use Disorders:
Client Characteristics
Higher Rates
• Males
• Younger
• Lower education
• Single or never married
• Good premorbid
functioning
• History of childhood
conduct disorder
• Antisocial personality
disorder
• Higher affective
symptoms
• Family history SUD
Factors Influencing Prevalence
of Substance Use Disorders:
Sampling Location
Higher Rates
• Emergency rooms
• Acute psychiatric
hospitals
• Jails
• Homeless
• Urban setting
(drugs)
• Rural setting
(alcohol)
Clinical Epidemiology
1. Rates higher for people in treatment
2. Approximately 50% lifetime, 25-35% current
substance misuse
3. Rates are higher in acute care,
institutional, shelter, and emergency
settings
4. Substance misuse is often missed in
mental health settings
Why Focus on Dual
Disorders?
1. Substance misuse is the most common
concurrent disorder in persons with SMI
2. Significant negative outcomes related to
substance abuse:
a) Clinical relapse & rehospitalization
b) Demoralization
c) Family stress
d) Violent behavior
e) Incarceration
f) Homelessness
g) Suicide
h) Medical illness
i) Infections diseases
j) Early mortality
3. Outcomes improve when substance misuse remits
4. Poor treatment is expensive for families & society
Poor Outcomes of People with
Mental Illness in Addiction
Treatment Settings
• Higher rates of drop out from treatment
• Addiction to more substances
• More problems in legal, social, functional,
medical outcomes
• Higher relapse rates into addiction
• Lower utilization of self-help groups
Major Subgroups of
Comorbid Clients
• Severely mentally ill - psychotic
 Frequently
abuse moderate amounts of
substances
 Small amounts of substance use trigger
negative consequences
• Anxiety and/or depression
 Substance
symptoms
use can cause or worsen
 Frequently
misuse moderate to high
amounts of substances
• Personality Disorders
 Antisocial
& borderline most common
 Frequently abuse high amounts of
substances
Reasons for High Comorbidity
Rates of Severe Mental Illness and
Substance Misuse
•
•
•
•
Berkson’s Fallacy
Self-medication
Super-sensitivity to effects of alcohol & drugs
Socialization motives
 Acceptance
 Peer pressure
 Facilitates interactions/intimacy
• Common factors for mental illness and
substance misuse
 Poverty/deprivation
 Neurocognitive
impairment
 Conduct disorder/antisocial personality
disorder
Self-Medication:
 More symptomatic clients don’t misuse more
substances
 Substance selection unrelated to type of
symptoms experienced
 Types of substances misused unrelated to
psychiatric diagnosis
 Self-medication may contribute to maintaining
substance misuse, but probably doesn’t
explain high rates
Super-sensitivity Model:
 Biological sensitivity increases vulnerability to
effects of substances
 Smaller amounts of substances result in
problems
 “Normal” substance use is problematic for
clients with SMI but not in general population
 Sensitivity to substances, rather than high
amounts of use, makes many clients with
mental illness different from general
population
Stress-Vulnerability Model
Medication
Substance
Abuse
Biological
Vulnerability
Severity
of SMI
Stress
Coping
Status of Moderate Drinkers with
Schizophrenia 4 - 7 Years Later (N=45)
100%
80%
60%
55.6
40%
20%
20.0
24.4
Moderate
Drinker
Alcohol
Use
Disorder
0%
Abstinent
Source: Drake & Wallach (1993)
CD, ASPD, and Recurrent Substance Use Disorders
Alcohol Use Disorder
70%
60%
50%
40%
30%
20%
10%
0%
Cannabis Use Disorder
63.2
60.0
60%
52.6
50%
41.7
36.0
40%
29.3
30%
20%
25.0
13.8
10%
0%
Cocaine Use Disorder
40%
36.8
30%
No ASPD/CD
CD Only
20%
Adult ASPD Only
12.5
10%
N=293
4.9
8.0
Full ASPD
0%
Source: Mueser et. al. (1999)
Support for Super-sensitivity Model:
Clients with concurrent disorders are less likely to
develop physical dependence on substances
 Standard measures of substance misuse are less
sensitive in clients with SMI
 Clients are more sensitive to effects of small
amounts of substances
 Few clients are able to sustain “moderate” use
without impairment
 Super-sensitivity accounts for some increased
comorbidity

Treatment Barriers
• Historical division of services and training
• Sequential and parallel treatments
• Organizational and categorical funding
barriers in the public sector
• Eligibility limits, benefit limits, and payment
limits in the private sector
• Primary/secondary distinction
Primary/Secondary Distinction
• Often difficult or impossible to make, even
with extensive observation
• Delays treatment of one disorder
• Is used to shift responsibility from one service
to another
• Best to assume that both disorders are
primary until proven otherwise
Integrated Treatment
• Mental health and substance abuse treatment
 Delivered concurrently
 By the same team or group of clinicians
 Within the same program
 The burden of integration is on the
clinicians
Other Features of Dual
Disorder Programs
•
•
•
•
•
No “wrong door”
Comprehensive services
Minimization of treatment-related stress
Harm reduction philosophy
Motivational enhancement (e.g., stages
of change, stages of treatment)
No “Wrong Door”
• Multiple doors to services exist in systems
• Substance abuse or mental health services accessed
through entry to system via multiple doors
• Referrals to different services stigmatize “other”
disorder & decrease chances of engagement
• No referrals to other service providers:
consultation/collaboration needed
Services Provided
• Comprehensive assessment and monitoring
of mental health & substance abuse
• Concurrent treatment of dual disorders
• Coordination & collaboration among
treatment staff
• Teamwork among treatment providers &
recognition of staff expertise
Promises of a “No Wrong
Door” Policy
• Successful engagement of most clients in treatment
• Systematic assessment of mental health & substance
abuse disorders
• Uniform record keeping
• No need to follow up on referrals
• More effective treatment of concurrent disorders,
leading to fewer relapses, hospitalizations,
detoxifications, etc.
• Cost savings
Challenges of a “No Wrong
Door” Policy
• Need for comprehensive & undifferentiated training of
all clinicians
• How to integrate care while maintaining specialty
foci?
• Formation of integrated treatment teams: clinicians
from same service or different services?
• Fear of loss of professional identity
• Turf issues & concern over funding streams that
target specific disorders
• Need for treatment guidelines to address specific
dual disorders
What are the Stages of
Treatment?
1.
2.
3.
4.
5.
6.
Based on the stages of change: Pre-contemplation,
contemplation, preparation, action, maintenance
Stages of treatment: Engagement, persuasion,
active treatment, & relapse prevention
Not linear; progress forward, relapses back
Stage of treatment determines primary goal
Goals determine interventions
Multiple options at each stage
Overview of Assessment of
Substance Abuse in Clients
with Severe Mental Illness
Detection
Classification
Functional
Assessment
Functional
Analysis
Treatment
Planning
Detection
Goal: To identify clients who may be experiencing
problems related to substance use
Strategies
1. Maintain a high “index of suspicion”
2. Explore past history of substance abuse first
3. Be aware of clients characteristics related
to substance abuse (age, sex, antisocial
personality, etc.)
4. Use laboratory tests
5. Carefully monitor clients who “use” but
do not “misuse” substances
6. Use self-report screens for substance
abuse
7. Evaluate clients for common
consequences of substance abuse
in SMI
Common Consequences of
Substance Abuse in SMI
• Relapse & rehospitalization
• Financial problems
• Family burden
• Housing instability &
homelessness
• Non-compliance with
treatment
•
•
•
•
•
•
Violence
Suicide
Legal problems
Prostitution
Health problems
Infectious disease
risky behaviors
Classification
Goal: To determine whether client meets criteria for
a substance use disorder
Strategies
1. Use Clinician Rating Scales for Alcohol
and Drug Use
2. Base ratings on multiple sources of
information
 Client self-reports
 Clinician
observations
 Reports of other treatment providers
 Reports of significant others
 Records, laboratory tests
3. Make rating every 6 months
4. Rate based on the worst period over the
past 6 months
5. Stick to the evidence -- don’t assume
consequences of substance abuse
6. Gather additional information when
necessary
Clinician Rating Scales
1. Abstinent
2. Use without impairment
3. Abuse
4. Dependence
5. Dependence with institutionalization
Substance Use Disorders
(Based on DSM Series)
Substance Abuse
• A pattern of substance use resulting in
significant problems in the areas of social or
psychological functioning, work, health, or
use in dangerous situations
Substance Dependence
• The use of substances that results in
development of the dependence syndrome
Psychological Dependence
• Use of more substance than intended, unsuccessful
attempts to cut down, giving up important activities to
use substances, or spending lots of time obtaining
substances
Physical Dependence
• Development of tolerance to effects of substance,
withdrawal symptoms following cessation of
substance use, use of substance to decrease
withdrawal symptoms
Functional Assessment
• Goals: To understand client’s functioning across
different domains & to gather information about
substance use behavior
• Domains of Functioning
1. Psychiatric disorder
2. Physical health
3. Psychosocial adjustment (family & social
relationships, leisure, work, education,
finances, legal problems, spirituality)
• Dimensions of Substance Misuse
1.
2.
3.
4.
5.
6-Month Time-Line Follow-Back Calendar
Substances misused & route of use
Patterns of use
Situations in which use occurs
Reported motives for use
• Social
• Coping
• Recreational
• Structure/sense of purpose
6. Consequences of use
Social Factors for Substance
Use
• Does consumer have non-substance using
peers?
• Is substance use serving to maintain a preexisting social network?
• Is substance use facilitating social contacts with
a new social network?
• Can person resist offers to use substances?
• Is the person lonely?
Common Symptoms &
Self-Medication
•
•
•
•
•
Depression, suicidal thoughts
Anxiety, nervousness, tension
Hallucinations
Delusions of reference & paranoia
Sleep disturbance
Recreational/Leisure &
Substance Use
• Boredom/relaxation as motivation for using
substances
• What does the client do for fun?
• Hobbies, sports?
• What is person’s involvement with others in
recreational activities?
• Does the person not participate in activities which
he/she previously did?
Other Motivating Factors for
Using Substances
• Escape from unpleasant memories of psychosis
(“sealing over”)
• Increased unstructured time due to dropout from
school or not working
• Demoralization due to shattering of personal goals &
assault on self-esteem
• Ready access to money through family, disability
income
• Normal rebelliousness of delayed adolescence/early
adulthood
Functional Analysis
• Goal: To identify factors which influence or control
substance use behavior
• Constructing a Payoff Matrix
1. List advantages & disadvantages of using
substances, & advantages & disadvantages of not using
2. Use all available information from functional
assessment
3. Consider advantages & disadvantages from the
client’s perspective
4. View different reasons listed as hypotheses about
maintaining factors, not established facts; reasons may
change as new information emerges
5. If client is using, the pros of using & cons of
not using should outweigh the pros of not
using & cons of using
Pay-Off Matrix
Using Substances
Advantages
Disadvantages
Not Using Substances
Common Advantages & Disadvantages of
Using Substances & Not Using
Using Substances
Advantages
¥
¥
¥
¥
¥
¥
¥
¥
¥
¥
¥
¥
Feels good
Acceptance & friendship when using with peers
Decreased social anxi ety
Feel "normal" when using with others
Escape from b elief one is a "failure" or has not
lived up to expectations
Relief from d epression or anxiety
Reduction or distraction from h allucinations
Help getting to sleep
Improved attention & concentration
Decreased medica tion side effects
Something to look forward to
Reduction in craving or withdrawal symptoms
Not Using Substances
¥
¥
¥
¥
¥
¥
¥
¥
¥
¥
Disadvantages
¥
¥
¥
¥
¥
¥
¥
¥
¥
¥
¥
¥
Conflict with significant others
Housing instability & homelessness
Relapses & rehospitaliza tions
Financial problems
Legal problems
Infectious diseases & other me dical illnesses
Increased exposure to trauma
Inability to pursue goals & meet major role
obligations (worker, student, spouse, parent)
Physical dependence leading to need for greater
amo unts
Sociopathic or crimi nal socia l network
Lac k of an intimate relationship
Increased hallucinations or paranoia
¥
¥
¥
¥
¥
¥
¥
¥
¥
¥
¥
¥
Better relationships with significant others
Stable & independent housing
Improved control & stability of psychiatric
illness
Financial stability & control over one's
money
Stay out of jail/prison
Minimize d exposure to infectious diseases
& better management of medical illnesses
Reduced exposure to trauma
Improved ability to pursue goals & meet
major role obligations (worker, student,
spouse, parent)
Better social relationships, including
intimate relationships, with people who
really care
No physical dependence
Lac k of positive feelings
Awkwardness or peer p ressure from friends
who use substances
Social i solation because no friends who
don't use
Social an xiety
Feel "abnormal" because of stigma from
mental illness
Confrontation with belief that one is a
failure
Persistent depression or anxiety
Distress due to hallucinations
Poor attention & concentration
Troubling medication side effects
Nothing to do or look forward to
Cravings or withdrawal symptoms
Examples of Interventions Based
on the Payoff Matrix
Using Subs tances
Not Using Substance s
Advan tages
¥
¥
Naltr exone
Disulfir am
¥
¥
¥
¥
¥
¥
Contingen t reinforcement
Comm unit y reinforcement
Motivationa l i ntervie wing
Dec isi ona l balance me thod
Educa tion abou t dua l dis orders
Persua sion g roups
Disadvan tage s
¥
¥
¥
Disulfir am
Financ ial paye eship
Cond iti ona l discha rge from
psychiatric hosp it al
Probation or parole cond ition
¥
Skil ls training for social
competence
Identifying new social out le ts
Teaching skill s for coping
wit h d ist ressful symptoms
Pharmacological treatment of
distressful symp toms
Deve loping alt ernative
recreationa l activities
Creating new & meaning
pursuit s (e.g., work , schoo l,
parenting)
Teaching strategies for coping
wit h cravings
¥
¥
¥
¥
¥
¥
¥
Treatment Planning
•
•
Goals: To determine which interventions are most
likely to be effective & how to measure outcome
Steps:
1. Engage the client & significant others
2. Assess motivation to change
3. Select target behaviors, thoughts, emotions to
change
4. Identify interventions to address targets
5. Choose measures to assess effects of
intervention
What do We do During
Engagement?
• Goal: To establish a working alliance
with the client
• Clinical Strategies
1. Outreach
2. Practical assistance
3. Crisis intervention
4. Social network support
5. Legal constraints
What do We do During
Persuasion?
• Goal: To motivate the client to address substance
abuse as a problem
• Clinical Strategies
1. Psychiatric stabilization
2. “Persuasion” groups
3. Family psychoeducation
4. Rehabilitation
5. Structured activity
6. Education
7. Motivational interviewing
What do We do During
Active Treatment?
• Goal:

To reduce client’s abuse of substance
• Clinical Strategies
1. Self-monitoring
2. Social skills training
3. Social network interventions
4. Self-help groups
5. Substitute activities
6. Cognitive-behavioral techniques to address:
 High risk situations
 Craving
 Motives for substance use
What do We do During
Relapse Prevention?
• Goals:
 To maintain awareness of vulnerability & expand
recovery to other areas
• Clinical Strategies
1. Self-help groups
2. Cognitive-behavioral & supportive interventions to
enhance functioning in:
 Work, relationships, leisure activities, health, &
quality of life
Recovery Mountain
• Combat demoralization related to relapses
• Reframe relapses as part of road to recovery
• Don’t loose sight of gains made between
relapses
• Learning experience, modify relapse
prevention plan
Stages of Substance Abuse
Treatment
1. Pre-engagement: No contact with a counselor.
2. Engagement: Irregular contact with a counselor.
3. Early Persuasion: Regular contact with a
counselor, but no reduction in substance misuse.
4. Late Persuasion: Regular contact with a
counselor and reduction in substance misuse (<
1 month).
5. Early Active Treatment: Reduction in
substance use (> 1 month).
6. Late Active Treatment: No misuse for 1-6
months.
7. Relapse Prevention: No misuse 6-12 months.
8. Remission: No misuse for over one year.
What is Motivation?
“Motivation can be understood not as
something that one has, but as something
that one does. It involves recognizing a
problem, searching for a way to change,
and then beginning and sticking with that
change strategy.”
- W.R. Miller
Motivational Interviewing
Goal:
• To create a salient dissonance or discrepancy
between the person’s current substance abuse
behavior and important personal goals.
Core Principles
1. Express empathy
2. Establish personal goals
3. Develop discrepancy
4. Roll with resistance
5. Support self-efficacy
Expressing Empathy
Goal:
 To understand the client’s world
Strategies
 Active listening skills
• Good eye contact
• Responsive facial expression
• Body orientation
• Verbal and non-verbal “encouragers”
 Reflective listening
 Asking clarifying questions
 Avoiding challenges, expressing doubt, judgment,
and unsolicited advice
Establishing Personal Goals
Goal:
 To establish personal, meaningful goals that
the client wants to work towards
Strategies
 Talk with clients about their:
• Aspirations
• Thoughts about how things could be
different
• Fantasies
 Get
to know what the client was like in the
past, such as:
 Preferred activities
 Admired people
 Personal ambitions
 Don’t discourage ambitious goals
Examples of Goals
• Finding a job
• Completing high
school
• Finding a girlfriend
• Getting married
• Rekindling a
relationship with an
old friend
• Going fishing with
one’s father
• Getting one’s own
apartment
• Resuming parenting
responsibilities
• Re-establishing
relationships with
siblings
• Handling one’s own
money
• Buying a car
Developing Discrepancy
Goal:
 To develop a salient discrepancy between the
client’s personal goals and current substance
abuse behavior
Strategies
 Use the Socratic Method to help clients reach their
own conclusions
 Break large, long-term goals into smaller, more
manageable steps
 Use questions to explore with clients how
substance abuse may interfere with achieving
personal goals
 Avoid direct argumentation
Rolling with Resistance
Goal:
 To overcome resistance to change in
substance abuse behavior
Strategies
 Avoid over-pathologizing: resistance is normal
 Rather than opposing resistance, explore it
 Identify specific concerns about attaining
sobriety and problem solve about these
concerns
Supporting-Efficacy
Goal:
 To foster hope in clients that they can achieve
desired changes
Clinical Strategies
 Express optimism that change is possible
 Reframe prior “failures” as examples of clients’
personal strengths and resourcefulness to
cope with problems such as:
• Homelessness
• Trauma
• Persistent psychotic symptoms
• Time spent in jail
 Acknowledged past setbacks while
remaining positive about possible change
 Review examples of client’s achievements
in other areas
Rationale for Group-Based
Treatment for Clients with CoOccurring Disorders
• Substance abuse frequently occurs in a social
context
• Opportunity for social support
• Development of a new, healthier social networks
• More economical than individual treatment
• Greater variety of feedback to clients
• Modeling available from clients who have
progressed to later stages of treatment
Common Themes of Group
Treatments for CoOccurring Disorders






Education about effects of substance abuse
Non-confrontational
Avoidance of high levels of negative affect in group
Fostering social support between group members
Encouraging attendance at self-help groups for
substance abuse
Addressing problems related to mental illness
Different Models of Group
Intervention for Dual Disorders
•
•
•
•
12-Step
Education/supportive
Social skills training
Stage-wise
Persuasion groups
Active treatment groups
Problems with Self-Help
Groups
•
•
•
•
•
•
•
•
Sponsorship
Spirituality and delusions
Abstract concepts
Inability to relate to losses
Early stages of treatment
Poor social skills
Paranoia
Medication as a “drug”
Self-Help Approach
•
•
•
•
Present as one option
Go meeting shopping
Don’t forget about the mental illness
If it doesn’t work, don’t push it
Persuasion Groups
•
•
•
•
•
•
•
Primarily for persuasion stage
Keep short (or take a break)
Co-facilitated
Open format
Non-confrontational
Recurrent use common
Refreshments
Persuasion Groups
• Peer role models
• Self-help materials not useful
• Psychoeducation about substance
abuse & mental illness
• Weekly meetings
• Use of hospitalizations, trouble with the
law, etc.
Persuasion Groups
Group Guidelines:
 Confidentiality
 Alcohol
& drug use
 Active psychosis
 No disruptive behavior
 Member check-in
Persuasion Groups
Topics:
 Guest
speakers
 Genograms
 War stories
 Skills training
 Printed materials
Active Treatment Groups
• Stages of active treatment/relapse
prevention
• Co-facilitated
• Weekly meetings
• More confrontational
• Peer role models
• Self-help materials helpful
Active Treatment Groups
Topics:
 Triggers
& high risk situations
 Skills training, anger management,
assertiveness, coping, etc.
 Relaxation & imagery
 Stress management
Social Skills Training
Groups
• Primary goal is to teach new skills, not
foster insight
• Multiple training sessions conducted
weekly
• Sessions conducted by 2 leaders following
pre-planned curriculum
• Planned generalization of skills into clients’
natural environment
Stage-wise Skills Training
• Appropriate at all stages of treatment
• Early stages (engagement, persuasion)
focus on motives for using substances
• Later stages (active tx., relapse
prevention) also address high risk
situations, including refusal skills
Motives for Substance Use
and Relevant Skills
• Socialization: conversational skills,
making friends
• Leisure & recreation: developing new
recreational activities
• Coping: expressing negative feelings,
cognitive restructuring to address
anxiety & depression
High Risk Situations
•
•
•
•
•
Offers to use at a party
Running into a former dealer
Feeling depressed or anxious
Invitation to use with boy/girlfriend
Money or paycheck in pocket
When to Use Stage-wise or
Skills Training Groups
• Both can be useful; encourage clients to
try both types
• Stage-wise groups more abstract,
process oriented
• Skills training groups more concrete,
easier for clients with cognitive
impairments
Why is Family Work with Dual
Disorders Important ?
• Many DD clients have contact with
family members who provide support
and assistance
• Caregiving burden is increased when
clients have DD
• Loss of family support is a major
contributor to housing instability and
homelessness in DD clients
• Relatives may unintentionally encourage
substance abuse in DD clients
• DD clients and their relatives often know
little about mental illness and substance
use interactions
• Family intervention is effective for both
disorders
Combined Results of Family Intervention
Programs on 2-Year Cumulative Relapse
Rates in Schizophrenia (11 Studies)
Goals of Family Intervention for DD
• Educate family members about mental illness,
substance abuse, and their treatment
• Increase coping skills for all family members
• Increase social support
• Decrease burden of care on family members
• Decrease stress on clients
• Decrease substance use
• Improve client functioning
• Decrease hospitalizations & homelessness
Overview of Intervention
• Two treatment modalities:
– Behavioral Family Therapy (BFT) (time-limited)
– Multiple-family groups (time-unlimited)
• BFT for psychoeducation, communication skills,
problem solving skills
• Multiple-family groups for additional psychoeducation
& social support
• BFT precedes multiple-family groups
• Clients & relatives involved in all sessions
Goals of BFT
• To establish a working alliance between the
treatment team & family
• To provide education to family members about
mental illness, substance abuse, & the their
treatment
• To enhance family coping through:
– Improved communication
– Teaching problem solving skills
Format of BFT
•
•
•
•
•
•
•
Individual family sessions
Relatives & clients included
“Open door” policy for reluctant participants
One hour sessions
Sessions conducted on a “declining contact basis”
Treatment is long-term, not short-term
Focus is on learning new information & skills, not fostering
insight
Phases of BFT
Phase of BFT
Sessions
1. Connecting
Client Stage of
Treatment
Engagement
2. Assessment
Engagement
2-5
3. Psychoeducation
Persuasion or
active treatment
Persuasion, active
treatment, or relapse
prevention
Persuasion, active
treatment, or relapse
prevention
Active treatment or
relapse prevention
6-8
4. Communication
skills training
5. Problem-solving
6. Termination
1-3
1-6
5-15
1
Engaging the Family
• Be respectful, non-judgmental, empathic
• Explain you want to help family members
become “members of the treatment team”
• Describe goals of family program as education,
reducing relapses, & helping client
independence
• Allow relatives to vent & “tell their story”
Assessment of the Family
• For Each Family Member
What do they understand about the disorders?
What are their short-term goals?
What are their long-term goals?
What interferes with obtaining their goals?
• For the Family as a Unit
What are their strengths and weaknesses?
What deficits do they have in communication skills?
What deficits do they have in problem solving skills?
Principles of
Psychoeducation
•
•
•
•
•
•
•
•
Education is interactive
Use multiple teaching aids
Connote client as the “expert”
Elicit relatives’ experience & understanding
Avoid conflict & confrontation
Education is a long-term process
Evaluate understanding
Review materials as often as possible
Educational Topics
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Schizophrenia/schizoaffective/bipolar
Medications
Stress-vulnerability
Role of the family
Basic facts about alcohol & drugs
Alcohol & drugs: Motives & consequences
Alcohol & drugs : Treatment
Infectious diseases
Communication skills
Communication Skills
• Communication & mental illness
• Improving communication
– Get to the point
– Keep communications focused
– Speak clearly
– Use feeling statements
– Speak only for yourself
– Focus on behavior
Communication Skills
• Other Communication
– Listening
– Eye Contact
– Voice Tone
– Facial Expression
• Key Communication Skills
Communication Problems That
Warrant Skills Training
• Frequent fights (loud voice tone, anger,
strong irritability that derails family work)
• Pejorative put-downs
• Snide, sarcastic, caustic comments
• Lack of verbal reinforcement between
members
• Difficulty being specific when talking about
feelings and behavior
Problem Solving
1. Define the Problem
2. Brainstorm
3. Evaluate Solutions
4. Choose Best Solution or Combination
5. Plan on How to Implement Solution
6. Follow up Plan
Format of Problem Solving
• “Chairman” leads family through steps of
problem solving
• “Secretary” records problems solving efforts
• Focus is on getting all members’ input AND
sticking to steps of problem solving
• If at first you don’t succeed, problem solve again
• Always schedule a follow-up meeting
Examples of Topics for Family
Problem-Solving
• Identify alternative socialization outlets
• Responding to offers to use substances
• Determining strategies for dealing with
persistent symptoms
• Exploring alternative recreational activities
• Finding work or other meaningful activities
Avoiding the
Blame/Demoralization Trap
Don’t blame the client for substance abuse or
relapses because:
 Substance abuse is a disorder for which
clients are no more responsible than their
primary psychiatric symptoms
 Clients with most severe substance abuse
need professional help the most; many others
improve spontaneously
 Remember that the clients are doing the best
they can
To avoid demoralization:
 Remember: integrated treatment works in the
long run
 There is usually no obvious “best solution”
 Adopt a collaborative-empirical approach to
treatment
 View relapses as an inevitable part of the
recovery process
 Develop a case formulation based on a
functional analysis to guide treatment
Clinical Resources
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Bellack, A. S., Bennet, M. E., & Gearon, J. S. (2007). Behavioral Treatment for Substance Abuse in People with Serious
and Persistent Mental Illness. New York: Taylor and Francis.
Center for Substance Abuse Treatment. (2005). Substance Abuse Treatment for Persons With Co-Occurring Disorders.
(Vol. DHHS Publication No. (SMA) 05-3922). Rockville, MD: Substance Abuse and Mental Health Services Administration.
Centre for Addiction and Mental Health. (2001). Best Practices: Concurrent Mental Health and Substance Use Disorders.
Ottowa: Health Canada.
IDDT Toolkit: http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/default.asp
Graham, H. L., Copello, A., Birchwood, M. J., & Mueser, K. T. (Eds.). (2003). Substance Misuse in Psychosis: Approaches
to Treatment and Service Delivery. Chichester, England: Wiley.
Graham, H. L., Copello, A., Birchwood, M. J., Mueser, K. T., Orford, J., McGovern, D., Atkinson, E., Maslin, J., Preece, M.
M., Tobin, D., & Georgion, G. (2004). Cognitive-Behavioural Integrated Treatment (C-BIT): A Treatment Manual for
Substance Misuse in People with Severe Mental Health Problems. Chichester, England: John Wiley & Sons.
Mercer-McFadden, C., Drake, R. E., Clark, R. E., Verven, N., Noordsy, D. L., & Fox, T. S. (1998). Substance Abuse
Treatment for People with Severe Mental Disorders: A Program Manager's Guide. Concord, NH: New HampshireDartmouth Psychiatric Research Center.
Mueser, K. T., & Gingerich, S. (2006). The Complete Family Guide to Schizophrenia: Helping Your Loved One Get the
Most Out of Life. New York: Guilford Press.
Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated Treatment for Dual Disorders: A Guide to Effective
Practice. New York: Guilford Press.
Roberts, L. J., Shaner, A., & Eckman, T. A. (1999). Overcoming Addictions: Skills Training for People with Schizophrenia.
New York: W.W. Norton.
Research Reviews
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Brunette, M. F., Mueser, K. T., & Drake, R. E. (2004). A review of research on residential programs for people with severe
mental illness and co-occurring substance use disorders. Drug and Alcohol Review, 23, 471-481.
Cleary, M., Hunt, G., Matheson, S., Siegfried, N., & Walter, G. (2008). Psychosocial interventions for people with both
severe mental illness and substance misuse (Review). Cochrane Database of Systematic Reviews, Issue 1. Art. No.:
CD001088. DOI: 10.1002/14651858.CD001088.pub2.
Donald, M., Dower, J., & Kavanagh, D. J. (2005). Integrated versus non-integrated management and care for clients with
co-occurring mental health and substance use disorders: A qualitative systematic review of randomised controlled
trials. Social Science & Medicine, 60, 1371-1383.
Drake, R. E., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G. R. (1998). Review of integrated mental
health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24, 589-608.
Drake, R. E., Mueser, K. T., Brunette, M. F., & McHugo, G. J. (2004). A review of treatments for clients with severe mental
illness and co-occurring substance use disorder. Psychiatric Rehabilitation Journal, 27, 360-374.
Drake, R. E., O'Neal, E., & Wallach, M. A. (2008). A systematic review of psychosocial interventions for people with cooccurring severe mental and substance use disorders. Journal of Substance Abuse Treatment, 34, 123-138.
Kavanagh, D. J., & Mueser, K. T. (2007). Current evidence on integrated treatment for serious mental disorder and
substance misuse. Journal of the Norwegian Psychological Association, 5, 618-637.
Mueser, K. T., Drake, R. E., Sigmon, S. C., & Brunette, M. F. (2005). Psychosocial interventions for adults with severe
mental illnesses and co-occurring substance use disorders: A review of specific interventions. Journal of Dual
Diagnosis, 1, 57-82.
Mueser, K. T., Kavanagh, D. J., & Brunette, M. F. (2007). Implications of research on comorbidity for the nature and
management of substance misuse. In P. M. Miller & D. J. Kavanagh (Eds.), Translation of Addictions Science into
Practice (pp. 277-320). Amsterdam: Elsevier.