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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 Epidemiology
11. . Rates higher for people in treatment
22.. Approximately 50% lifetime, 25-35% current substance misuse
33.. 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 remits
4.4. 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
StrategiesStrategies
11.. Maintain a high “index of suspicion”
22.. Explore past history of substance abuse first
33.. Be aware of clients characteristics related
to substance abuse (age, sex, antisocial
personality, etc.)
44. . Use laboratory tests
55.. 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
ClassificationClassification
GoalGoal:: To determine whether client meets criteria for a substance use disorder
StrategiesStrategies
11. . Use Clinician Rating Scales for Alcohol and Drug Use
22.. 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 months
44.. Rate based on the worst period over the past 6 months
55.. Stick to the evidence -- don’t assume consequences of substance abuse
66.. Gather additional information when necessary
Clinician Rating ScalesClinician Rating Scales
1. 1. Abstinent
2. 2. Use without impairment
3. 3. Abuse
4. 4. Dependence
5. 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 Functioning
1. 1. Psychiatric disorder
2.2. Physical health
3.3. 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
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 groups
2. 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 InterviewingInterviewing
Goal:Goal:• To create a salient dissonance or discrepancy
between the person’s current substance abuse behavior and important personal goals.
Core PrinciplesCore Principles
1. 1. Express empathy
2. 2. Establish personal goals
3. 3. Develop discrepancy
4. 4. Roll with resistance
5. 5. Support self-efficacy
Expressing EmpathyExpressing EmpathyGoalGoal::
To understand the client’s world
StrategiesStrategies 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 towards
StrategiesStrategies 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 behavior
StrategiesStrategies 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-Efficacy
GoalGoal:: 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 Groups
Group Guidelines:ConfidentialityAlcohol & drug useActive psychosisNo disruptive behaviorMember check-in
Persuasion GroupsPersuasion Groups
Topics: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 MemberWhat 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 Solving
1. 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.
• Mueser, K. T., & Gingerich, S. (2006). The Complete Family Guide to Schizophrenia: Helping Your Loved One Get the Most Out of Life. New York: Guilford Press.
• Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated Treatment for Dual Disorders: A Guide to Effective Practice. New York: Guilford Press.
• Roberts, L. J., Shaner, A., & Eckman, T. A. (1999). Overcoming Addictions: Skills Training for People with Schizophrenia. New York: W.W. Norton.
Research Reviews• Brunette, M. F., Mueser, K. T., & Drake, R. E. (2004). A review of research on residential programs for people with severe
mental illness and co-occurring substance use disorders. Drug and Alcohol Review, 23, 471-481.• Cleary, M., Hunt, G., Matheson, S., Siegfried, N., & Walter, G. (2008). Psychosocial interventions for people with both
severe mental illness and substance misuse (Review). Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD001088. DOI: 10.1002/14651858.CD001088.pub2.
• Donald, M., Dower, J., & Kavanagh, D. J. (2005). Integrated versus non-integrated management and care for clients with co-occurring mental health and substance use disorders: A qualitative systematic review of randomised controlled trials. Social Science & Medicine, 60, 1371-1383.
• Drake, R. E., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G. R. (1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24, 589-608.
• Drake, R. E., Mueser, K. T., Brunette, M. F., & McHugo, G. J. (2004). A review of treatments for clients with severe mental illness and co-occurring substance use disorder. Psychiatric Rehabilitation Journal, 27, 360-374.
• Drake, R. E., O'Neal, E., & Wallach, M. A. (2008). A systematic review of psychosocial interventions for people with 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.