Psychology of Addictive Behaviors
September 1993 Vol. 7, No. 3, 168-172
© 1993 by the Educational Publishing Foundation
This project was funded by Office of Treatment Improvement Grant 1 H87 TI00050-0100. I thank Gretchen Blais, Barbara Hart, and Marta Obuchowsky, for their work on the dual diagnosis project and their comments on this article.
This article reviews significant issues and developments in the effort to improve treatment for individuals with comorbid disorders. Important research questions are identified, some clinical and policy issues for treatment programs are described, and training strategies designed to upgrade the quality of care are proposed. A multidimensional treatment and training effort in Oakland, California, is provided as an illustration.
Issues in the treatment of the dual diagnosis patient are moving to the foreground as a result of increasingly widespread recognition of how substance use influences mental health disorders. The most recent of the large-scale epidemiological studies in the area of dual diagnosis ( Regier et al., 1990 ) documents the pervasiveness of the problem. In that study, more than 20,000 people were interviewed in the total community and institutional sample, and various relationships between the coexisting disorders were described. The lifetime prevalence for mental disorders (excluding substance abuse) was estimated at 22.5%, with an odds ratio of 2.7 for also having an addictive disorder (lifetime prevalence of 29%). Among those with an alcohol disorder, 36.6% had comorbid disorders, with the highest rate occurring in the prison population ( Regier et al., 1990 ).
These findings confirm the impressions of many clinicians that coexisting disorders are a given in most settings and that addressing such disorders needs to be an integral part of the treatment process. The authors of the study also noted that the comorbidity rates for the severe disorders, such as schizophrenia and bipolar and antisocial personality disorder, are particularly high and greatly complicate treatment. In addition, they noted the importance of addressing mental disorders as a part of substance abuse prevention efforts and urged the empirical testing of the notion that early recognition and treatment is a promising prevention strategy for substance abuse.
This article highlights some of the important areas of activity needed to adequately address the research, treatment, and training issues that have been identified.
Despite these findings that indicate a high prevalence of dual diagnosis, a recent assessment of the level and sources of research funding for mental health and substance abuse showed that such funding is extremely limited and disproportionate to the overall costs to society ( Pincus & Fine, 1992 ). Pincus and Fine noted that the direct and indirect costs associated with dual disorders amount to more than $1,000 for each man, woman, and child in the United States. They reported that although these disorders accounted for 12% of total U.S. health costs in fiscal year 1988, they accounted for only 4.7% of health research support. They recommended greater coalition building and advocacy to expand the breadth and depth of research resources for the field.
A research program announcement at the federal level ( U.S. Department of Health and Human Services, 1990 ) described an initiative intended to "improve the understanding of service use by persons with these multiple diagnoses, and to identify ways to improve the effectiveness of services delivered to them" (p. 1). As a means of fostering this goal, proposals are encouraged that explore patterns of service use by those with multiple disorders, including longitudinal service use and use across the primary medical care, mental health, and alcohol and drug abuse treatment systems. In addition to understanding which services are used, it is important to identify the most desirable modes of service delivery. Hence, proposals are solicited that examine the interaction of different providers and coordination of care over time.
Clinicians in the field have identified additional problems. Although "networking" is currently a popular concept, it is by no means clear that complex clinical problems can be adequately addressed in this manner. Optimally, care providers need to maintain ongoing communication, which may break down even within a single treatment system offering multiple resources (such as large medical centers) and is even more difficult to maintain between care providers in different systems. Inadequate capacity and long waiting lists may render the assembly of key services a vain hope. Funding sources, in an effort to avoid duplication, encourage linkages, but practical obstacles often defeat the effort. It is important to develop a framework for evaluating the consortium approach, especially to determine the point at which additional resources are needed to provide the key ingredients of care in a timely manner. Attention to the problems of dual diagnosis patients can be expected to foster increasing interaction between mental health and addiction treatment providers, thus bridging the gap that occurred as the addiction treatment system went through its rapid but relatively separate evolution. Many areas of mistrust remain between practitioners. It will be important to clarify the different assumptions of providers in each system and to develop a common language.
Addiction treatment providers are currently turning to case management, widely used within mental health, to address some of the problems they encounter. Graham and Timney (1990) noted that as use becomes more widespread, the same dilemmas, ambiguities, and controversies emerge. These problems revolve around the scope of the case manager's role (e.g., provide or arrange therapy) and the qualifications and training needed to be effective, the clients most likely to benefit, the range of advocacy activities considered appropriate, the locus of case management activities within the system, and the difficulties in establishing standards for effective case management. Graham and Timney pointed to the need for research on how case management should be done and to what extent it contributes to the recovery process. Such case management may often be essential to help dual diagnosis patients address the daunting complexities and sometimes conflicting expectations that arise when they are obliged to deal with different systems of care.
With respect to conducting research on actual treatment, the clinical issues themselves are complex. A literature search as few as 5 years ago yielded very sparse pickings; today, there is a growing avalanche in both the psychiatric and substance abuse journals. Many issues remain to be addressed through systematic empirical studies. The federal initiative ( U.S. Department of Health and Human Services, 1990 ) specifically included the following commonly recognized clinical problem areas: (a) decision making to establish optimal treatment plans, how to determine priorities in selecting what to treat initially, and how to establish prognosis and probable course of treatment; (b) how standard treatment with psychotropic medications needs to be modified; (c) assessment of diagnostic accuracy and unrecognized co-occurrence; (d) studies of the appropriateness and effectiveness of the treatment provided, including studies of the long-term course; (e) studies of the importance of self-medication as a factor in the development of disorders; and (f) studies with special populations, such as those with adolescent onset, elderly people, those with the most severe mental disorders, ethnic minorities, the homeless population, and those in rural areas. A sustained investigation of these issues has the promise of clarifying treatment dilemmas and pointing to more effective strategies.
It would be useful to define the characteristics of a dual diagnosis program, and existing programs need to specify what is offered. There is currently much incentive to use the term dual diagnosis program but wide variability in how it is used. Many treatment providers' "dual diagnosis" programs do not include the severely thought-disordered patient for whom the mental health system is most interested in obtaining assistance. Programs vary widely in their policies on admitting patients on medication and on how medication is supplied and monitored. They also differ in the ways in which physicians are used and integrated into the program. It is important to be clear on the credentials and training of counseling staff, especially the extent to which staff members are cross trained, and how these factors affect the population accepted for treatment.
At present, it is not unusual for providers in the same community to be isolated from one another and unaware of what is available nearby. Organizations for networking are needed to facilitate the sharing of information. It is useful to have a resource directory that includes a listing of different modalities (e.g., therapeutic communities, board and care homes, halfway houses, day treatment, and outpatient treatment) available in the community. Also, it is helpful to have a listing of appropriate self-help groups (e.g., 12-step meetings) that are more receptive to dual diagnosis patients, as well as other self-help groups that may be appropriate. The gulf between the mental health and addiction treatment systems has heightened the need for case managers who can ask the precise questions needed to determine whether a particular resource has the appropriate expertise.
Cross training is a key factor that will determine the effectiveness of treatment efforts in the long run. Many of today's cadre of experienced supervising professionals (psychiatrists, psychologists, social workers, and marriage and family counselors) were trained before courses in addictive disorders were widely available, much less mandatory. Hence, they are ill equipped themselves and unable to upgrade the assessment and treatment skills of others, yet they are highly influential in teaching and setting policy. The many clinical and legal hazards thus produced have been described by Zweben and Clark (1990-1991) . Manifestations of substance abuse imitate other clinical entities in ways that frequently remain unrecognized and untreated. Hence, many opportunities for prevention and early intervention are missed, and progress in already-difficult clinical situations is further retarded. Although dual diagnosis patients are admittedly complex and require long-term, coordinated efforts, many treatment providers probably become unnecessarily discouraged because they have failed to include basic and ordinarily effective interventions. A vigorous cross-training effort will remedy some of these problems and result in more effective, hybrid treatment programs.
As an aid in designing effective programs, it would be helpful to document the extent to which assessment and treatment of substance abuse are integrated into the required curriculum for physicians, psychologists, social workers, marriage and family counselors, and others in allied professional groups. Goals for increased efforts in medical and graduate schools need to be formulated and implemented. It would also be important to know what states regulate training and how they do so. For example, California Senate Bill 1796 (1984) mandated such training for professionals entering training around the time of the bill, and California Assembly Bill AB 3314 (1990) put licensed professionals on notice that basic competencies are expected. It would be useful to have a national picture of which states have such legislation, as well as its scope.
Other training questions focus on how best to teach substance abuse treatment staff about psychiatric disorders. What are the relevant competencies, and what are the limits? What is the best way to approach training concerning addictive disorders for those in mental health settings? What types of patients are best handled in those settings, and which patients should be referred to more highly specialized treatment? What training materials are currently in existence, and what materials need to be developed? Clearly, materials are needed for practitioners at several different levels of sophistication. Systematic technology transfer efforts are also needed to expose practitioners to relevant findings of the research literature. The federal government, which funds most of this research, has begun such initiatives. For example, the Center for Substance Abuse Treatment is developing a treatment improvement protocol for dual diagnosis patients to be distributed to treatment agencies and policymakers. Such materials contribute significantly to building a foundation, but more extensive activities are needed to accelerate momentum.
In spring 1990, the newly created Office of Treatment Improvement (now, the Center for Substance Abuse Treatment) released a request for proposals for its Critical Populations Grant Program, a group of demonstration projects for treatment program and treatment system enhancements for a number of underserved populations. Patients with mental illness and substance abuse disorders were specifically included, and the East Bay Community Recovery Project was a recipient of such an award to serve this group (in addition to ethnic minorities and residents of public housing). The dual diagnosis program added resources to serve the clinic's existing patient population. It also launched activities to enhance the ability of mental health service providers to address their patients' substance use and the ability of addiction treatment professionals to address possible comorbid disorders.
A Current Example
Within the clinic itself, staff welcomed the additional resources (particularly the added psychiatry time) and increased the number of difficult dual diagnosis patients they were willing to accept on their caseloads. Having a psychiatrist more readily available improved the clinic's response capacity when patients decompensated or became suicidal. Determining needs for psychotropic medication and managing patients on medication were enormously facilitated by making these services available within the familiar treatment setting. Although finding psychiatrists who specialize in addiction medicine remains a difficult task, on-site training resources permitted development of that expertise in psychiatrists who were willing to undertake the effort. When sufficient physician time was not available from addiction medicine specialists, interested psychiatrists were recruited and supplied with reading material, information about relevant conferences, and access to consultants with expertise in dual disorders. In this way, new resources were developed.
In their activities outside the clinic, in the mental health system, and in related programs, staff members focused on community consultation and staff development. Their efforts were concentrated in community mental health centers, board and care homes, and psychiatric halfway houses. They assisted in designing activities (e.g., specialized groups) and in training staff in the mental health setting. Training included systematic lecture presentations as well as case discussions and other kinds of dialogue. Staff members also served as cotherapists in a variety of groups. Although much of the training focused on the assessment and treatment of addictive disorders, it was emphasized that, in the dual diagnosis population, any amount of alcohol or drug use may undermine progress and needs to be addressed. Through regular exposure, staff members in other settings increased their competence and confidence and began to think differently about drug and alcohol use in their patient population.
In providing this kind of assistance, one goal was to increase the understanding of the board and care and halfway house operators to make them more effective in addressing substance use behaviors. For example, one halfway house required patients to sign a contract not to drink or use drugs while living there and promptly discharged anyone who did so. However, staff members were troubled at this uniform response because they believed that some patients had a better chance than others at regaining their grip. Providing more realistic ways of looking at relapse and formulating differentiated treatment strategies were very beneficial to the staff. Previously, relapse had been a vaguely defined phenomenon, and staff members felt uneasy about minimizing consequences for drug-using behavior if they retained the patient and guilty about premature termination if they decided on discharge. Clarifying relapse patterns and ways to address them allowed staff members to evolve a more constructive decision-making process that did not always leave them feeling that they had done the wrong thing.
Within the addiction treatment system, misunderstandings about medication are an important barrier to effectiveness with the dual diagnosis population. Despite the clear Alcoholics Anonymous (1984) position that appropriately prescribed medication is quite compatible with 12-step program participation, many providers continue to assume that such medication diminishes recovery and are reluctant to explore the possibility that it is needed. For example, one residential program requested psychological testing on a client they were about to discharge for continuing to use drugs. Our staff member identified a depressive disorder and recommended a medication consultation. The patient was placed on desipramine and demonstrated improved impulse control, self-esteem, and ability to engage in treatment in a more meaningful way. Despite this experience, some resistance is still evident on the part of the residential treatment staff, suggesting that a more systematic educational process that provides information and an opportunity for discussion is needed to effect a shift. The staff's clinical experience has confirmed that, for some patients, psychotropic medication actually facilitates their entering recovery by providing them the assistance needed to establish abstinence. In the presence of adequate (although ambivalent) motivation, such difficulties in establishing abstinence may reflect coexisting disorders that need to be addressed through medication and other interventions. Unfortunately, it is still quite common in addiction treatment settings for providers to underestimate the influence of the coexisting disorder and to communicate their biases against medications to their clients, who are then reluctant to comply with recommended medication regimens.
A key issue to emerge from this project is the need to provide a forum to develop policies and procedures appropriate to different settings. For example, halfway houses are different from shelters, and providers may expect too much or too little from their residents. They also become overwhelmed and demoralized when they feel that what they do is ineffective. Some providers who see clients for only brief periods of time feel ineffective because clients do not establish abstinence. Clarifying these questions, including appropriate time frames in which to expect improvement, goes a long way toward enhancing morale as well as refining treatment responses.
A second issue that has been identified is the difficulty dual diagnosis patients have in obtaining the full range of services (i.e., food, housing, and treatment). Indeed, the complex needs of the dual diagnosis patient require sophisticated case management resources not currently available. Upcoming activities will focus on providing updated resource directories with key elements specified (e.g., the number of hours a psychiatrist is on site) and linkages to key services in the community.
Effectively addressing the problems of dual diagnosis patients requires efforts at the national, state, and federal levels to define the important issues, especially barriers, and to formulate a plan. Currently, it appears that because the problem is so multidimensional, no one institution is the obvious place to initiate a plan, and efforts are thus more haphazard than is desirable. It is hoped that the remainder of this decade will see the emergence of vigorous leadership and coordinated efforts to create a system that adequately addresses the needs of the dual diagnosis patient at whatever his or her point of entry into the system and provides a sustained level of care.
Alcoholics Anonymous.(1984). The AA member-Medications and other drugs. Report from a group of physicians in AA. New York: Alcoholics Anonymous World Services.
California Assembly Bill 3314. An act to add Section 29 to the Business and Professions Code related to healing arts.
California Senate Bill 1796. Amendment to the Business and Professions Code relating to licensing.
Graham,K. & Timney,C. B. (1990). Case management in addictions treatment. Journal of Substance Abuse Treatment, 7 181-188.
Pincus,H. A. & Fine,T. (1992). The 'anatomy' of research funding of mental illness and addictive disorders. Archives of General Psychiatry, 49 573-579.
Regier,D. A., Farmer,M. E., Rae,D. S., Locke,B. Z., Keith,S. J., Judd,L. L. & Goodwin,F. K. (1990). Comorbidity of mental disorders with alcohol and other drug abuse. Journal of the American Medical Association, 264 2511-2518.
U.S. Department of Health and Human Services.(1990). Research on services for persons with mental disorders that co-occur with alcohol and/or drug abuse disorders. Washington DC: Author.
Zweben,J. E. & Clark,H. W. (1990-1991). Unrecognized substance misuse: Clinical hazards and legal vulnerabilities.
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