Integrated Treatment Integrated Treatment for Dual Disordersfor Dual Disorders

Kim T. Mueser, Ph.D.Dartmouth Medical School

Dartmouth Psychiatric Research CenterKim.t.mueser@dartmouth.edu

Any Substance Use DisorderAny Substance Use Disorder

0

10

20

30

40

50

60

Prevalence % of Substance Use

Disorder

Gen.Pop Schiz BPD MD OCD Phobia PD

Rates of Lifetime Substance Use Disorder (SUD) Rates of Lifetime Substance Use Disorder (SUD) among Recently Admitted Psychiatric Inpatients (N among Recently Admitted Psychiatric Inpatients (N

= 325) = 325) (Mueser et al., 2000)(Mueser et al., 2000)

0

25

50

75

100

% of Clients with SUD

Schizophrenia Schizoaffective Disorder Bipolar Disorder Major Depression

Factors Influencing Factors Influencing Prevalence of Substance Prevalence of Substance

Use Disorders: Use Disorders: Client CharacteristicsClient Characteristics

Higher RatesHigher 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 Factors Influencing Prevalence of Substance Prevalence of Substance Use Disorders: Sampling Use Disorders: Sampling

LocationLocation

Higher RatesHigher Rates• Emergency rooms• Acute psychiatric

hospitals• Jails

• Homeless• Urban setting

(drugs)• Rural setting

(alcohol)

Clinical EpidemiologyClinical Epidemiology11. . Rates higher for people in treatment22.. Approximately 50% lifetime, 25-35%

current substance misuse33.. Rates are higher in acute care,

institutional, shelter, and emergency settings

44.. Substance misuse is often missed in mental health settings

Why Focus on Dual Why Focus on Dual Disorders?Disorders?

11.. Substance misuse is the most common concurrent disorder in persons with SMI

22.. Significant negative outcomes related to substance abuse:a) Clinical relapse & rehospitalizationb) Demoralization

c) Family stress d) Violent behavior

e) Incarcerationf) Homelessnessg) Suicide h) Medical illness i) Infections diseasesj) Early mortality

3.3. Outcomes improve when substance misuse remits4.4. Poor treatment is expensive for families & society

Poor Outcomes of People Poor Outcomes of People with Mental Illness in with Mental Illness in Addiction Treatment Addiction Treatment

SettingsSettings• 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 Major Subgroups of Comorbid ClientsComorbid Clients

• Severely mentally ill - psychotic Frequently abuse moderate amounts

of substances Small amounts of substance use

trigger negative consequences• Anxiety and/or depression

Substance use can cause or worsen symptoms

Frequently misuse moderate to high amounts of substances

• Personality Disorders Antisocial & borderline most common Frequently abuse high amounts of

substances

Reasons for High Reasons for High Comorbidity Rates of Severe Comorbidity Rates of Severe Mental Illness and Substance Mental Illness and Substance

MisuseMisuse• 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-MedicationSelf-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 ModelSuper-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 ModelStress-Vulnerability Model

BiologicalVulnerability

SubstanceAbuse

Medication Stress Coping

Severityof SMI

Status of Moderate Drinkers Status of Moderate Drinkers with Schizophrenia 4 - 7 Years with Schizophrenia 4 - 7 Years

Later (N=45)Later (N=45)

55.6

20.0 24.4

0%

20%

40%

60%

80%

100%

Abstinent ModerateDrinker

AlcoholUse

Disorder

Source: Drake & Wallach (1993)

Alcohol Use Disorder

29.3

41.7

60.0 63.2

0%10%20%30%40%50%60%70%

CD, ASPD, and Recurrent Substance Use DisordersCD, ASPD, and Recurrent Substance Use Disorders

Cocaine Use Disorder

4.9

12.58.0

36.8

0%

10%

20%

30%

40%No ASPD/CD

CD Only

Adult ASPD Only

Full ASPD

Cannabis Use Disorder

13.8

25.0

36.0

52.6

0%

10%

20%

30%

40%

50%

60%

N=293

Source: Mueser et. al. (1999)Source: Mueser et. al. (1999)

Support for Super-sensitivity ModelSupport 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 BarriersTreatment 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 DistinctionPrimary/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 TreatmentIntegrated 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 Other Features of Dual Disorder ProgramsDisorder 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”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 ProvidedServices 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 Promises of a “No Wrong Door” PolicyDoor” 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 Challenges of a “No Wrong Door” PolicyDoor” 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 What are the Stages of Treatment?Treatment?

1. Based on the stages of change: Pre-contemplation, contemplation, preparation, action, maintenance

2. Stages of treatment: Engagement, persuasion, active treatment, & relapse prevention

3. Not linear; progress forward, relapses back4. Stage of treatment determines primary goal5. Goals determine interventions 6. Multiple options at each stage

Overview of Assessment Overview of Assessment of Substance Abuse in of Substance Abuse in

Clients with Severe Clients with Severe Mental IllnessMental Illness

Detection

Classification

Functional Assessment

Functional Analysis

Treatment Planning

DetectionDetectionGoalGoal:: To identify clients who may be

experiencing problems related to substance use

StrategiesStrategies11.. Maintain a high “index of suspicion”22.. Explore past history of substance abuse first33.. Be aware of clients characteristics related

to substance abuse (age, sex, antisocial personality, etc.)

44. . Use laboratory tests55.. Carefully monitor clients who

“use” but do not “misuse” substances

66.. Use self-report screens for substance abuse

77.. Evaluate clients for common consequences of substance abuse in SMI

Common Consequences of Common Consequences of Substance Abuse in SMISubstance Abuse in SMI

• Relapse & re-hospitalization

• Financial problems• Family burden• Housing instability

& homelessness• Non-compliance

with treatment

• Violence• Suicide• Legal problems• Prostitution• Health problems• Infectious disease

risky behaviors

ClassificationClassificationGoalGoal:: To determine whether client meets

criteria for a substance use disorderStrategiesStrategies11. . Use Clinician Rating Scales for Alcohol

and Drug Use22.. Base ratings on multiple sources of

information Client self-reports

Clinician observations Reports of other treatment providers Reports of significant others Records, laboratory tests

33.. Make rating every 6 months44.. Rate based on the worst period over the

past 6 months55.. Stick to the evidence -- don’t assume

consequences of substance abuse66.. Gather additional information when

necessary

Clinician Rating ScalesClinician Rating Scales1. 1. Abstinent2. 2. Use without impairment3. 3. Abuse4. 4. Dependence5. 5. Dependence with

institutionalization

Substance Use DisordersSubstance Use Disorders(Based on DSM Series)(Based on DSM Series)

Substance AbuseSubstance 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 DependenceSubstance Dependence• The use of substances that results in

development of the dependence syndrome

Psychological DependencePsychological 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 DependencePhysical Dependence • Development of tolerance to effects of substance,

withdrawal symptoms following cessation of substance use, use of substance to decrease withdrawal symptoms

Functional AssessmentFunctional Assessment• GoalsGoals:: To understand client’s functioning

across different domains & to gather information about substance use behavior

• Domains of FunctioningDomains of Functioning1. 1. Psychiatric disorder2.2. Physical health3.3. Psychosocial adjustment (family & social

relationships, leisure, work, education, finances, legal problems, spirituality)

• Dimensions of Substance MisuseDimensions of Substance Misuse1.1. 6-Month Time-Line Follow-Back Calendar2.2. Substances misused & route of use3.3. Patterns of use4.4. Situations in which use occurs5.5. Reported motives for use

• Social• Coping• Recreational• Structure/sense of purpose

6.6. Consequences of use

Social Factors for Social Factors for Substance UseSubstance Use

• Does consumer have non-substance using peers?

• Is substance use serving to maintain a pre-existing 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 &Common Symptoms &Self-MedicationSelf-Medication

• Depression, suicidal thoughts• Anxiety, nervousness, tension• Hallucinations• Delusions of reference & paranoia• Sleep disturbance

Recreational/Leisure & Recreational/Leisure & Substance UseSubstance 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 Other Motivating Factors for Using Factors for Using

SubstancesSubstances• 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 AnalysisFunctional Analysis• GoalGoal:: To identify factors which influence or

control substance use behavior• Constructing a Payoff MatrixConstructing a Payoff Matrix

1. 1. List advantages & disadvantages of using substances, & advantages & disadvantages of not using

2.2. Use all available information from functional assessment

3.3. Consider advantages & disadvantages from theclient’s perspective

4. 4. View different reasons listed as hypotheses about maintaining factors, not established facts; reasons may change as new information emerges

5.5.If client is using, the pros of using & cons ofnot using should outweigh the pros of notusing & cons of using

Pay-Off MatrixPay-Off Matrix

Advantages

Disadvan-tages

Using Substances Not Using Substances

Common Advantages & Disadvantages of Common Advantages & Disadvantages of Using Substances & Not UsingUsing Substances & Not Using

Using Substances Not Using Substances

Advantages • Feels good• Acceptance & friendship when using with peers• Decreased social anxiety• Feel "normal" when using with others• Escape from belief one is a "failure" or has not

lived up to expectations• Relief from depression or anxiety• Reduction or distraction from hallucinations• Help getting to sleep• Improved attention & concentration• Decreased medication 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• Minimized 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, includingintimate relationships, with people whoreally care

• No physical dependence

Disadvantages • Conflict with significant others• Housing instability & homelessness• Relapses & rehospitalizations• Financial problems• Legal problems• Infectious diseases & other medical illnesses• Increased exposure to trauma• Inability to pursue goals & meet major role

obligations (worker, student, spouse, parent)• Physical dependence leading to need for greater

amounts• Sociopathic or criminal social network• Lack of an intimate relationship• Increased hallucinations or paranoia

• Lack of positive feelings• Awkwardness or peer pressure from friends

who use substances• Social isolation because no friends who

don't use• Social anxiety• 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 Examples of Interventions Based on the Payoff Matrixon the Payoff Matrix

Using Substances Not Using Substances

Advantages • Naltrexone• Disulfiram

• Contingent reinforcement• Community reinforcement• Motivational interviewing• Decisional balance method• Education about dual disorders• Persuasion groups

Disadvantages • Disulfiram• Financial payeeship• Conditional discharge from

psychiatric hospital• Probation or parole condition

• Skills training for socialcompetence

• Identifying new social outlets• Teaching skills for coping

with distressful symptoms• Pharmacological treatment of

distressful symptoms• Developing alternative

recreational activities• Creating new & meaning

pursuits (e.g., work, school,parenting)

• Teaching strategies for copingwith cravings

Treatment PlanningTreatment Planning• GoalsGoals: : To determine which interventions are

most likely to be effective & how to measure outcome

• Steps:Steps:1. Engage the client & significant others2. Assess motivation to change3. Select target behaviors, thoughts, emotions

to change4. Identify interventions to address targets5. Choose measures to assess effects of

intervention

What do We do During What do We do During Engagement?Engagement?

• GoalGoal: : To establish a working alliance with the client

• Clinical StrategiesClinical Strategies1.1. Outreach2.2. Practical assistance3.3. Crisis intervention4.4. Social network support5.5. Legal constraints

What do We do During What do We do During Persuasion?Persuasion?

• GoalGoal: : To motivate the client to address substance abuse as a problem

• Clinical StrategiesClinical Strategies1.1. Psychiatric stabilization2.2. “Persuasion” groups3.3. Family psychoeducation4.4. Rehabilitation5.5. Structured activity6.6. Education7.7. Motivational interviewing

What do We do During What do We do During Active Treatment?Active Treatment?

• Goal:Goal: To reduce client’s abuse of substance

• Clinical StrategiesClinical Strategies1. 1. Self-monitoring2. 2. Social skills training3. 3. Social network interventions4. 4. Self-help groups5. 5. Substitute activities6. 6. Cognitive-behavioral techniques to address:

High risk situations Craving Motives for substance use

What do We do During What do We do During Relapse Prevention?Relapse Prevention?

• Goals:Goals: To maintain awareness of vulnerability & expand

recovery to other areas• Clinical StrategiesClinical Strategies

1.1. Self-help groups2. 2. Cognitive-behavioral & supportive interventions to

enhance functioning in: Work, relationships, leisure activities, health, &

quality of life

Recovery MountainRecovery 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 Stages of Substance Abuse TreatmentAbuse Treatment

1. 1. Pre-engagementPre-engagement:: No contact with a counselor.

2. 2. EngagementEngagement:: Irregular contact with a counselor.

3. 3. Early PersuasionEarly Persuasion:: Regular contact with a counselor, but no reduction in substance misuse.

4. 4. Late PersuasionLate Persuasion: : Regular contact with a counselor and reduction in substance misuse (< 1 month).

5. 5. Early Active TreatmentEarly Active Treatment:: Reduction in substance use (> 1 month).

6. 6. Late Active TreatmentLate Active Treatment:: No misuse for 1-6 months.

7. 7. Relapse PreventionRelapse Prevention:: No misuse 6-12 months.

8. 8. RemissionRemission:: No misuse for over one year.

What is Motivation?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 Motivational InterviewingInterviewingGoal:Goal:

• To create a salient dissonance or discrepancy between the person’s current substance abuse behavior and important personal goals.

Core PrinciplesCore Principles1. 1. Express empathy2. 2. Establish personal goals3. 3. Develop discrepancy4. 4. Roll with resistance5. 5. Support self-efficacy

Expressing EmpathyExpressing EmpathyGoalGoal::

To understand the client’s worldStrategiesStrategies

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 Establishing Personal GoalsGoals

GoalGoal:: To establish personal, meaningful goals

that the client wants to work towardsStrategiesStrategies

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 GoalsExamples 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 Developing DiscrepancyDiscrepancy

GoalGoal:: To develop a salient discrepancy between the client’s

personal goals and current substance abuse behaviorStrategiesStrategies

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 ResistanceRolling with ResistanceGoalGoal::

To overcome resistance to change in substance abuse behavior

StrategiesStrategies 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-EfficacySupporting-EfficacyGoalGoal::

To foster hope in clients that they can achieve desired changes

Clinical StrategiesClinical 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 Rationale for Group-Based Treatment for Clients with Treatment for Clients with

Co-Occurring DisordersCo-Occurring 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 Common Themes of Group Treatments for Group Treatments for

Co-Occurring DisordersCo-Occurring 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 Different Models of Group Intervention for Dual Intervention for Dual

DisordersDisorders

• 12-Step• Education/supportive• Social skills training• Stage-wise

Persuasion groupsActive treatment groups

Problems with Self-Problems with Self-Help GroupsHelp 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 ApproachSelf-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 GroupsPersuasion Groups• Primarily for persuasion stage• Keep short (or take a break)• Co-facilitated• Open format• Non-confrontational• Recurrent use common• Refreshments

Persuasion GroupsPersuasion 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 GroupsPersuasion GroupsGroup Guidelines:

ConfidentialityAlcohol & drug useActive psychosisNo disruptive behaviorMember check-in

Persuasion GroupsPersuasion GroupsTopics:Topics:

Guest speakers Genograms War stories Skills training Printed materials

Active Treatment Active Treatment GroupsGroups

• Stages of active treatment/relapse prevention

• Co-facilitated• Weekly meetings• More confrontational• Peer role models• Self-help materials helpful

Active Treatment Active Treatment GroupsGroups

Topics:Topics: Triggers & high risk situations Skills training, anger management,

assertiveness, coping, etc. Relaxation & imagery Stress management

Social Skills Training Social Skills Training GroupsGroups

• 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 Stage-wise Skills TrainingTraining

• 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 Motives for Substance Use and Relevant SkillsUse 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 SituationsHigh 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-When to Use Stage-wise or Skills Training wise or Skills Training

GroupsGroups• 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 Why is Family Work with Dual Disorders Important ?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 Combined Results of Family Intervention Programs on 2-Year Intervention Programs on 2-Year

Cumulative Relapse Rates in Cumulative Relapse Rates in Schizophrenia (11 Studies)Schizophrenia (11 Studies)

64%

28% 28% 26%

0%

10%

20%

30%

40%

50%

60%

70%Standard Care(N=179)

Single FamilyTreatment(N=207)

Multiple FamilyGroup Treatment(N=266)

Single & MultipleFamily GroupTreatment(N=243)

Goals of Family Intervention Goals of Family Intervention for DDfor 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 InterventionOverview 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 BFTGoals 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 BFTFormat 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 BFTPhases of BFT

Phase of BFT Client Stage of Sessions Treatment1. Connecting Engagement 1-3

2. Assessment Engagement 2-5

3. Psychoeducation Persuasion or 6-8active treatment

4. Communication Persuasion, active 1-6 skills training treatment, or relapse

prevention5. Problem-solving Persuasion, active 5-15

treatment, or relapse prevention

6. Termination Active treatment or 1relapse prevention

Engaging the FamilyEngaging 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 FamilyAssessment 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 UnitWhat are their strengths and weaknesses?What deficits do they have in communication skills?What deficits do they have in problem solving skills?

Principles of Principles of PsychoeducationPsychoeducation

• 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 TopicsEducational 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 SkillsCommunication 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 SkillsCommunication Skills

• Other Communication– Listening– Eye Contact– Voice Tone– Facial Expression

• Key Communication Skills

Communication Problems Communication Problems That Warrant Skills That Warrant Skills

TrainingTraining• 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 SolvingProblem Solving1. Define the Problem2. Brainstorm3. Evaluate Solutions4. Choose Best Solution or

Combination5. Plan on How to Implement

Solution6. Follow up Plan

Format of Problem Format of Problem SolvingSolving• “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 Examples of Topics for Family Problem-SolvingFamily 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 Avoiding the Blame/Demoralization Blame/Demoralization

TrapTrapDon’t blame the client for substance Don’t blame the client for substance

abuse or relapses because: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 demoralizationTo 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 Hampshire-Dartmouth Psychiatric Research Center.

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• 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.

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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 co-occurring 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.