The International Journal of Psychosocial Rehabilitation

New Initiatives in the Treatment of the Chronic Patient with Alcohol/Substance Use Problems

Kathleen Sciacca, M.A., Executive Director,
Sciacca Comprehensive Service Development for Mental Illness,
Drug Addiction and Alcoholism

Development of Program
It is clearly evident that the lack of comprehensive treatment programs for persons with mental illness and alcohol/drug use problems has created a treatment dilemma in our mental health programs across the nation. It is also clear that there is movement to address this dilemma, and that a change in attitude among mental health professionals is taking place. For example, in my own travels in the mental health system I have heard the argument change from "We are not supposed to treat alcohol and/or drug problems in the mental health setting", to "Large numbers of our mentally ill patients also have problems with alcohol and drugs, how can we treat them, what can be done?"

Two and one-half years ago when I began work at one of Harlem Valley's Day Treatment programs I set out to answer the latter question. Through working with the patients themselves and by implementing a program within an existing psychiatric setting I began to find answers to that question. The answers that were discovered proved worthy of comprising a comprehensive treatment and proved to be applicable across separate treatment sites and multiple program formats. The first group, which began in December 1984, grew to eleven groups across six treatment sites, and includes clinics, day treatment, continuing treatment and residential program settings. Programs had to take place in our own treatment sites and utilize existing staff, without additional funds or special staffing. This led to the development of a treatment and group leadership approach that did not require extensive training in the area of substance abuse and alcoholism.

Treatment Approach and Philosophies

The issue that became most apparent when discussing substance abuse cases and issues with staff was the lack of knowledge or understanding of alcoholism and drug dependency as a disease--in effect, as an illness with symptoms that need to be brought into remission. Information about the disease concept of the use and abuse of various substances was disseminated to both staff and patients throughout our facilities, as an initial (and now an ongoing) approach to focusing attention on the problems. With the advent of a treatment group and a rise in information about the topics, some staff began to take interest in beginning a group in their service area.

In the summer of 1985 the administration formally identified staff members at each of the six sites who expressed an interest in providing group programming in their service area. The identified staff began meeting monthly for education, training, and the development and implementation of program initiatives. i.e. assessment tools, etc. The same staff members took on the responsibility of presenting educational materials to co-workers at their program sites. Staff reported feeling comfortable in providing treatment for patients with substance use problems through the use of an exploratory approach to understanding and treating these patients. Staff are not expected to present themselves as substance abuse experts when conducting treatment groups. Instead they can be comfortable in learning from and with the patients about many issues relevant to mental illness and concomitant substance use problems. However, staff do have a working understanding of the scope of the problem of substance use, its genetic predisposing factors, issues of tolerance levels, psychological dependencies, and the issues specific to combining these problems with the symptoms of a chronic mental illness. Staff and patients together begin to identify the interaction effects of these dual disorders, and it becomes clear to the patients that they are not being judged as ill behaved, or being sent away to another treatment program, or having to relate to a staff member who feels hopeless about their prognosis because they have a substance use problem. This clarity enables patients to trust the staff and their peers in the treatment setting, and to speak openly about their problems in a supportive environment.

Treatment Methods and Content

Few mental health professionals would argue with the fact that heavy confrontation, intense emotional jolting, and discouragement of the use of medication are detrimental approaches to the treatment of a chronically mentally ill person. Yet efforts to treat these patients have consisted mainly, of referring them to agencies that treat primary substance abusers who do not have a chronic disorder, where in many cases the above treatment methods and strategies are employed. It is no wonder that there is a great deal of resistance from these patients to following through with these referrals, as well as refusal by these agencies to take responsibility for an ongoing psychiatric disorder.

The treatment method we have found effective features non-confrontational approach. The group process focuses upon educational materials and permits each patient to discuss substance use issues in an impersonal way when this is more comfortable. Treatment staff do not seek to catch patients in lies; rather the objective is to engage patients in a process that offers a variety of information and points of view on the use of drugs and alcohol.

Peer support evolves out of each patient's eventual openness in discussing issues that are important in their lives as well as the relationship between substance use and other variables. Group leaders and members assist individuals to gain insight into the dynamics and patterns of the use of the substances when this is applicable. One of the essential learning experiences is the relationship of the use of drugs or alcohol to each patient's psychiatric symptoms. Group members begin to identify these interaction effects in others and in themselves.

Since group members are often resistant about attending self-help groups such as AA and NA, the model includes inviting AA and NA speakers to the group sessions to conduct open meetings and to tell their story to the group. These sessions are always highly effective, and they enable patients to benefit from identifying with recovering substance users even though they may not be comfortable or able to follow a full program of AA or NA. As a result of these sessions some patients do begin to attend these support groups in addition to our program.

Content areas of the educational process include areas that are unique to patients with a chronic mental illness, such as mixing medication with other substances, as well as areas that are similar between primary substance abusers and our patients-- for example, the fact that in many cases the use of the substances begins to control the patient's motivation and behavior versus the patient being in control of the use of the substance. Recurring themes such as the need to find new social networks are addressed through general discussion as well as through each individual's discussion of his or her own problems.

Overview of Program

Substance abuse groups are integrated into regular programming. For example, a patient in the day treatment program will attend all other programming as usual, except that he or she will attend a substance abuse group once or twice a week in lieu of another scheduled activity. In a clinic program patients will visit a medicating physician (where applicable), have regular sessions with a primary therapist, and attend the substance abuse group once a week. Patients are not segregated or removed from regular program activities. Communication between group leaders and primary therapists ensues regarding the patient's progress in the group. However, criteria for improvement include many areas and are not confined only to achievement of abstinence. A patient's ability to discuss his or her problems or usage openly may be a very important criterion for a patient who has kept his/her substance use a secret. Various insights that a patient may gain are considered progress. Collaborating with other treatment staff must not have the tone of reporting on a patient's substance use; therefore criteria need to be carefully thought out and conveyed to others.

Treatment groups last from forty-five minutes to one hour. Numbers of patients in groups vary from program to program; eight seems to be an optimal number of members. Groups should be kept to manageable size so that patients may explore their issues in depth when necessary and so that each patient has an opportunity to participate verbally in each session.

A brief alcohol and drug screening tool is presently in use for all intakes at Harlem Valley. The questions include clinical intuition as well as historical information, so that the patient in the denial phase of his or her problem does not have the problem go unnoted. Where positive signs of substance use problems are identified, liaisons at the facility are notified of this, so that they may follow the case until a decision is made about referring the patient to the substance use treatment group. If a patient is referred he or she is interviewed by the group leader(s). This interview is really the beginning of the treatment process and is a method of establishing a purpose for the patient's participation in the group, be it to view educational materials or to work on an acknowledged problem. The interview focuses on the patient's potential contribution to the group as well as what is expected of a participant.

The assessment questionnaire is an in-depth interview of many aspects of a patient's substance use history and present usage. Treatment guidelines are included so that therapists who are unfamiliar with substance abuse treatment can integrate its goals and objectives into the treatment plan. The assessment takes place during the process of treatment and is not used for screening.

We recognize the need for specific substance abuse treatment programs such as inpatient detoxes, rehab programs that last at least several weeks, adjunct support groups, etc. To generate successful referrals we have developed an interview for adjunctive treatment services. These agencies are visited by liaisons and assessment of the agencies' compatibility to our patients is obtained. We would like this effort to result in less rejection for our patients and more success outcomes where and when patients do engage in these programs.

 Administrative Support

A program of this scope and pioneering experimentation cannot be implemented or sustained without the support of administrators in a given agency. The Harlem Valley administration including our Executive Director, Clinical Director, Director for Community services and Associate Director for Community services, to name but a few, are innovators within our field. Without their foresight and support in allowing a program such as this to progress, I could not report to you that these patients can improve along numerous criteria, and these programs can take place within our existing mental health programs.

This article is a reprint from TIE-Lines, Published by the Information Exchange on Young Adult Chronic Patients, Bert Pepper, M.D., Executive Director Vol. 1V, No. 3, July 1987

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