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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 Not 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 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 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 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 • • • • • • • • • 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 • • • • • • • • • • 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 • • • • • • • • • 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.