Gary Beaulieu, M.S., LADC, LPC, CCS
Thomas Flanders, B.A., DNAD
About the Authors
Beaulieu, G., & Flanders, T. (2000) Uncovering the elements of success: working with co-occurring
disorders in residential support programs. International Journal of Psychosocial Rehabilitation. 4, 11-17
Today, nearly 10 million people in the United States suffer from at least one mental disorder and at least one substance-related disorder.1 According to national data from the Epidemiologic Catchment Area Survey (ECA), 47% of schizophrenic and 61% of bipolar (manic-depressive) patients have a substance-related disorder. 2 Historically, individuals with such severe mental health and complicating substance-abuse disorders were often entrusted to state mental hospitals. However, in today’s era of managed care and deinstitutionalization, the old state mental hospitals are no longer a readily available option of care. In America during the past four decades, the number of state and county mental hospital beds has decreased dramatically, from 559,000 beds in 1955 to 92,000 beds in 1990.3 This 84% decrease has left families, outpatient substance abuse and mental health providers, families and communities at large bewildered, overtaxed and struggling to find solutions for the treatment of individuals with co-morbid substance abuse and mental health disorders. In fact, today the majority of persons with co-occurring disorders receive no treatment at all.4 And, for those who are treated for both disorders, most find it necessary to receive services from two providers in two separate offices, one attempting to treat their mental illness and one attempting to treat their addictions.
However, both providers, in struggling to comprehend the complex interactivity that exists between dual disorders, often misdiagnose clients or simply diagnose one problem while the other is unintentionally overlooked. Given these two silos of uncoordinated care, treatment failure has become commonplace. Moreover, clients that seek support for their sobriety from outside groups often face serious dilemmas, e.g., "old-timers" in AA or NA often advocate total abstinence from chemicals, including those medications prescribed for the treatment of psychiatric disorders. Additionally, clients often feel they are stigmatized by their psychiatric disorders by others in the group or simply become confused by the 12-step process because of their functional abilities.
All in all, client access to appropriate support and treatment is limited to the few programs and support groups that are staffed with trained professionals and designed to provide services to individuals with co-occurring disorders. Desperate, clients who have been deinstitutionalized and living in the community, where ready access to drugs and alcohol has become more and more prolific, often turn to those individuals with whom they have the most contact--their "residential support" counselors. These mental health residential practitioners, provide hands-on community care in a variety of settings, including transitional/nontransitional group homes, family-style community residences, supervised/supported apartment programs or within the clients’ own residences in the community.
Although the services of these programs may vary in intensity depending on the individual’s level of need, they often include supervision; counseling; life skills training; medication monitoring and education; transportation; housing assistance; health and safety education; prevocational, social and communications skills training; and coordination with all other necessary psychiatric and support services. Actively engaged in caring for these clients on a daily basis, these unique counselors are left with the overwhelming task of finding solutions to the complex needs of the clients they serve in an environment that often seems stacked against them. Despite the political and economic factors that preclude their ability to take action, they have nonetheless been compelled to find new and low-cost approaches that have proven successful for their clients struggling with co-occurring substance-related and mental disorders.
One such approach that has proven to be successful for residential providers has been weekly psychoeducational groups in which clients can learn about and discuss issues related to their co-existing disorders. At the St. Vincent DePaul Society of Waterbury, Inc. Mental Health Division, a community-based mental health residential support program, they have integrated these groups into their model of care and have found them particular effective in helping individuals with co-occurring disorders maintain their sobriety. After years of experience in facilitating such groups, they consider certain elements to be the key ingredients of their success. The following outlines their suggestions:
Active listening is essential
As clients share the routine activities of their week, the perceptive listener can utilize this information to help clients make insightful connections. Rather than just conveying discrete bits of unrelated information and apparently disconnected events, a so-called humdrum story may, in fact, be the substrate within which lie patterns of behavior or several thematic elements that are interrelated by common symbols and metaphors. Once clients become aware of these connections, they can better identify their patterns, triggers to relapse and the hidden resources they possess that can help them in the recovery process. By refocusing, paraphrasing, interpreting and truly attending to what is being said, the keen facilitator can gather valuable information from even the most benign stories that may enable clients to gain extraordinary insights from ordinary conversation. Consequently, active listening can enable a facilitator to become a potent agent for change.
The importance of ceremony and ritual
Begin each group with a ritual and, when one maintains sobriety, celebrate his/her success enthusiastically. Not only can these small ceremonies be meaningful for the celebrant, but they can also be purposeful for the group as a whole, for it is through such celebrations that clients are given the opportunity to actively participate in the affirmation of their communal values, attitudes, beliefs and behaviors. These acts not only connect the individual to the ethos of the group, but also create a context in which the clients can metaphorically mark the significant events in their growth. By emphasizing participation in these rituals, the facilitator incites an aura of importance that help clients recognize the significance of process and process thinking in the context of their recovery and in the development of fuller and more enriching lives. Through celebration, clients can highlight their rites of passage to those new and fundamentally changed patterns that allow them to experience themselves and others in a qualitatively different way.
Be flexible; throw dogma to the wind
Do whatever is necessary to promote therapeutic or growth experiences. One should not become inflexible or fixed on a single model of change. What works for one client may not work for another. In working with individuals with co-occurring disorders, one should not exclude any particular model. In fact clients may respond to several approaches including elements of the 12-step process. However, it is important to recognize the cognitive and functional abilities of the individual participants and to modify or simplify each approach accordingly.
Invariably, members of the group will be in various stages of recovery and this heterogeneity can be invaluable. Involving senior members in the process gives them the opportunity to share their experiences and successes with others. As role models, they feel genuinely appreciated by the newer members of the group in the earlier stages of recovery. These newer members may not only gain valuable recovery information from older members, but also often rely on their sponsorship, support and inspiration. However, older members who have been involved in outside 12-step support groups can become rigid and locked into a one-way process of recovery. It is crucial that the facilitator discourage such dogma since every person in recovery has his/her own path to sobriety and may not fit neatly into a prepackaged process. And, it is also important to note that length of recovery time, although recognized in the group as something to be "honored," should not be portrayed as critical by the facilitator since any sober time is indicative of a desire for a better life. Intuitively, clients know what they need to stay sober. Draw these strategies out and allow clients to use what works for them.
Uncover hidden resources and motivations
One should strongly focus on developing the client’s internal sense of value, with the assumption that clients need to feel they are worth sobriety and an improved quality of life before they will take any steps towards positive change. Ultimately, clients need validation and that validation is key to facilitating sobriety in a population that has been stereotyped, demeaned and dehumanized. Helping clients realize that they deserve improvement in the quality of their lives enables them to embrace sobriety as an essential component of that improvement. Once this has been established, one can begin with the simple process of substituting good ideas for bad ones by suggesting alternative solutions.
Although it is important to offer a host of skills and problem-solving strategies to clients, very often practitioners are simply amplifying and/or making conscious the skills that clients already possess. By supporting their endeavors and showing them how they have solved similar problems in the past, the facilitator, in many cases, is simply awakening the clients’ reservoirs of inner resources which enable them to solve problems using their own unique styles. Ultimately, the members know more about what they need and what will work for them than the facilitator. Often clients simply require an opportunity to consider a variety of new ways of thinking or acting in order to alleviate their problems. Once clients identify the source of their pain and have learned the skills they require, they have adequate resources--conscious and/or unconscious problem-solving and coping mechanisms--that they can call upon to automatically spur self-corrective actions. Essentially, the job of practitioners is to harness the clients’ motivations and repository of resources of which they may or may not be aware.
Harness the power of the group
The facilitator should allow the group to shape their expressed desires. Through active listening and refocusing, the facilitator can often utilize the narratives of the group to reveal clients’ underlying needs. For instance, if a client begins a "war story," the facilitator can interpolate inquiries about the resolution of the problems revealed to help the group focus on what has been learned or gained from the experience, rather than on the minutiae of the story itself. More importantly, the facilitator can use this information collaboratively to decide on future psychoeducational formats, which may not only empower the group, but also help others in the group prevent such a relapse from occurring in their livIn this way, the facilitator can often reframe war stories into constructive topics for future discussion. During this process, clients will share the coping techniques and alternatives ways of preventing relapse which have worked for them with the idea that they do not have a monopoly on the truth but are proud to share their successes. When clients share with empathy, acceptance and understanding, the group members bond to form an all-important support system and recovery network. When this is established, the power of the group is revealed.
Focus on the positive and reserve judgement
Recognize that even small steps towards recovery are signs of improvement. Clients need to move ahead at their own pace learning from their experiences. It is important for the facilitator and the clients to view relapse not as failure, but as an opportunity to gain new understandings. Encourage the group to share good events, not just war stories, and focus on the positive aspects of their lives and recovery. When the facilitator maintains an atmosphere of positive regard, members will make comments that are supportive and appropriate. Too often clients are seen as a set of problems, disorders or unrealized treatment plans, rather than as individuals with positive interests, pleasures and motivations. Draw them out. Find out what’s beyond their problems, what motivates them, and what they do in their spare time. Clients are more than a set of disorders. A facilitator must be genuinely interested in the clients in order to build the relationships that are essential for success. If the facilitator is just performing a task and "talking the talk," the clients will "smell it out" and subsequently tend to withdraw. Intuitively, clients know that "what you are speaks louder than what you say."
Allow clients to share openly without fear of reprisal. The facilitator should encourage members to express the ongoing narratives of their lives freely so they are not restricted to addressing whether or not they used during the last week. Instead of asking each member, "Were you tempted this week?" try asking, "How have you improved this week?" If the facilitator has unconditional positive regard for the clients, they are more apt to view themselves as good individuals with bad problems to solve. If a client has been absent from a meeting, a simple "I really missed you!" will have a more desirable effect than questions that subtly imply that his or her absence was due to relapse. If the client feels accepted, he/she will most likely disclose that information without prompting. If a client admits to using, rather than dwelling on the relapse itself, the facilitator can ask, "What did you do to stop?" The facilitator must remain positive about relapse as part of the process of recovery, remembering that one can fall forward and still make progress, recognizing the validity of the adage, "If you fall and get up, you gain a step." And when clients are clean, reward them vigorously. The facilitator should never pass on an opportunity to praise or congratulate members on any achievement. In sum, treat every success as a major triumph and every relapse as a lesson learned.
"Spirituality" in recovery is best defined for clients as an awareness of and a connection to something or someone greater than themselves that can help them focus on their efforts to improve their lives. Once clients accept this concept and its importance in the recovery process, they are often faced with the question, "How can this greater consciousness live within me and outside of me at the same time? On its face this paradox may appear too difficult for often cognitively impaired clients to comprehend; however, teaching clients that this consciousness is within them and outside of them at the same time is not as difficult as it may appear. Familiar slogans like "I know I'm somebody, because God doesn't make any junk" reveal for clients their inherent value and capacity for improvement and their connection to a higher consciousness that is both internal and external.
For clients, an integral part of "knowing the will of (AA's) higher power" is to believe that such "will" includes the impetus to improve one’s life. Although this "will" is first understood as an external or abstract notion, once clients are able to internalize this "will," they begin to see it as a mirror from which they can view themselves and like what they see. Once they see their connection to spirituality from within and without, and strengthen their bond to it, their own concept of "self" becomes more positive and they are able to identify that ego strength on an emotional level, and become connected to that "good will" within themselves. With direction and frequent reinforcement from such professionals as group facilitators or residential counselors, clients develop a pattern of positive connections wherein exist the emotional and social (hence, spiritual) reserve to begin or to continue recovery.
It is essential that clients understand the link between their psychiatric treatment and their sobriety as well as their mental illness and their substance abuse. Education and support can help clients understand these fundamental concepts which are so important in preventing relapse. Fortunately, residential counselors are often in the unique position to reinforce these connections on an almost daily basis. Clients with co-occurring disorders must recognize that their substance abuse may be an attempt to cope with their psychiatric symptoms and that if they continue to drink or use drug, they will have even less control over their psychiatric problems, e.g., alcohol can worsen depression, and opiates or stimulants can increase auditory hallucinations, paranoia and delusional thinking.
Additionally, clients must understand that continued alcohol or drug abuse often results in medication non-compliance which only exacerbates their psychiatric symptoms and that without medication they are more likely to spiral out of control. Part of educating the clients about both problems must include the message that they deserve a better life and that sobriety is the foundation or the best path they can take towards the improvement they deserve. After all, clients have been attempting to feel good without first being able to feel good about themselves. The "double-whammy" of substance abuse and psychosis has greatly diminished their sense of control and ability to make sound decisions. Ultimately, the harmful choices they have made have introduced even more chaos into their lives and alienated them from many of the resources they could use to restore their independence and control. Through ongoing support and psychoeducation, clients are more likely to make the connections they require in order to improve their decision-making abilities, remain abstinent and maintain their medication regimen and psychiatric treatment compliance.
Incorporate relapse prevention in everyday activities
Professionals, such as residential counselors who work with clients with co-occurring disorders on a day-to-day basis, can often help them identify potential triggers or develop the coping mechanisms they require to avoid relapse. By identifying potentially stressful situations before they become critical, counselors can help clients either avoid stressors or cope with them on a daily basis. These relapse prevention plans should include not only the development of individualized strategies, but also hobbies, games, meditation and relaxation techniques, social events, the development of support networks, as well as diet and exercise routines which often have an immediate affect on the clients’ clarity of thought and decision-making abilities. Such self-directed activities help clients resist temptation, boost self-esteem, and develop the kind of associations that decrease the opportunities and the desire to drink or use drugs.
Overall, the techniques suggested throughout this article may not be appropriate for all providers or client populations. Ultimately, it is important design a program that works, one that not only meets the needs of the clients, but also the structure of the organization. It is equally important to recognize that clients may feel more relaxed and receptive to services when they are in familiar territory or on their own home turf. And, this is often the case for clients in mental health community-based residential programs where services are available to them within the same apartment complex or group home in which they reside. As a result, clients do not feel obliged to "fit in" to an artificial programmatic role and providers find it easier to develop rapport and work with those clients that are more prone to bouts of paranoia. Perhaps this home court advantage should be considered when allocating funds to providers who serve this ever taxing and growing population.
According to data from the National Co-morbidity Survey, between 41% and 65.5 % of those with an addictive disorder also have at least one mental disorder, and 51% of those with a mental disorder have at least one addictive disorder.5 Clearly, addiction and mental health providers can no longer avoid working with individuals with co-occurring disorders. They have become more of the norm than the minority. And, given their rates of chronic relapse and rehospitalization, it is obvious that the status quo is no longer adequate to meet the needs at hand. With this in mind, local, state and federal funding organizations need to renew their focus on the identification, treatment, and rehabilitation of individuals with co-morbid disorders and recognize that mental health residential providers are frequently left with the overwhelming task of serving these individuals on a day-to-day basis with often limited funding and training. Despite these barriers, community-based residential programs have done much to develop resources and services in their attempts to improve the lives of those in need. Nevertheless, more funding and a coordinated systemic effort are necessary in order for positive change to be realized—efforts that involve residential providers who can serve clients where they live, who can influence lives on a daily basis, and who can support these challenging clients in their rehabilitation and recovery.
1 Directors of the National Co-morbidity Survey and the Epidemiologic Catchment Area Survey. Kessler, R. (11/13/95). The Epidemiology of co-occurring addictive and mental disorders. National Co-morbidity Survey. Working Paper #9. Invited conference paper, presented at the Substance Abuse and Mental Health Services Administration sponsored conference; Improving services for individuals with co-occurring substance abuse and mental health disorders.
2 Reiger, D.A., Farmer, M.E., Rae, D., Locke, B.Z., Keith, S.J., Judd, L.L. & Goodwin, F.K., Comorbidity of mental disorders with alcohol and other drug abuse. Journal of American Medical Association 1990; 246: (19), 2511-2518.
3 Reiger, D.A., Epidemiology, in Kaplan and Sadock, Comprehensive textbook of psychiatry 1992; 390-392. Pepper, B., Massaro, J., Trans-institutionalization: Substance abuse and mental illness in the criminal justice system. Tie-Lines 1992; 9:2 1-4.
4 Osher, F.C., & Drake, R.E., Reversing a history of unmet needs: Approaches to care for persons with co-occurring addictive and mental disorders. American Journal of Orthopsychiatry 1996; 66(1): 4-11.
5 Kessler, R., Nelson, C., & McGonagle, K. The Epidemiology of co-occurring addictive and mental disorders: Implications for prevention and service utilization. American Journal, of Orthopsychiatry 1996; 66: 17-31.
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