(Mental illness and substance abuse/dependency)
Charles R. Goldman, M.D.
Perhaps the main problem in effectively treating this population is lack of suspicion that significant substance use is taking place. Interviewing the client/patient in detail (in a non-judgmental way) and also talking with others who know the client (including the case manager) are important approaches.
Careful diagnosis (using DSM-4) over a period of time (including a period of freedom from drugs and alcohol) is the next step after detection of a substance use problem.
Detection and diagnosis alone are not sufficient for planning treatment and rehabilitation. A thorough analysis of strengths and weaknesses, social network and readiness to change are required. This should include detailed medical assessment.
II. PHASES AND STAGES When mental illness and substance disorders coexist, they are both viewed as primary disorders, each requiring specific and intensive treatment (integrated, simultaneous). Both fit into the disease and recovery model.
A. Four phases of recovery (Minkoff, 1994)
1. Acute stabilization
2. Engagement in active treatment
3. Relapse prevention to maintain prolonged stabilization
4. Rehabilitation and recovery
Each disorder likely to be in different phase.
B. Stages of readiness to change (Brady, Hiam, Seamann et al, 1996; Prochaska, DiClemente, Norcross, 1992)
Client Cognitive-Behavioral Change
Stage Substance Abuse/Dependency Mental Illness Pre-contemplation Denies alcohol problem despite drunk-driving conviction. Will not acknowledge psychiatric difficulties after suicide attempt. Contemplation Occasionally "vows" to self to end crack-cocaine use but continues abuse. Thinks about calling the neighborhood mental health center but does not. Preparation Identifies an NA meeting with intent to attend. Makes appointment with a therapist. Action Begins sobriety. Attends therapy group regularly. Maintenance Avoids contact with old drinking friends. Monitors own emotional state and keeps appointments with psychiatrist.
III. FOUR STEP INTERVENTION STRATEGY (Minkoff, 1994)
1. Acknowledge your powerlessness. "See your role as helping the individual to make better choices for himself, not to get him to control his behavior so you will feel less worried or more successful."
2. Establish empathic detachment. "Experiencing genuine caring and concern from others is a powerful motivator in enhancing willingness to explore options for change."
Two elements of empathy: understanding the reasons for using substances, and respecting the choice to use substances for those reasons. "Let the person know that you may disagree with his choices, but you understand his pain, respect his choices, and respect his right to continue his behavior if it works for him."
3. Initiate an educational process. Individually, or in peer group setting. "Generally, over a period of months, the group begins to evolve into a culture encouraging control of substance use, and, ultimately, abstinence." Also important to provide education and support for families to help them maintain a stance of empathic detachment (ALANON).
4. Develop opportunities for empathic confrontation. Confrontation does not mean verbal attack; "it must occur within the context of a caring relationship, and involve genuine (not contrived) consequences of substance abuse. ... The individual is offered a `forced choice' between accepting help to change substance abusing behavior or accepting the negative consequences of continued use; ... the confronter does not `lose' if the individual continues to use substances." Confrontation may involve withholding a desired consequence (e.g., lower medication dose, referral to V.R. program, providing extra money) and should be tied to specific behaviors (e.g., being verbally abusive, rather than simply drinking). Consequences must make sense to the individual and not be seen as simply a means of coercion.
IV. MOTIVATIONAL INTERVIEWING - GENERAL PRINCIPLES
(Miller & Rollnick, 1991)
1. Express empathy
- Acceptance facilitates change
- Skillful reflective listening is fundamental
- Ambivalence is normal
2. Develop discrepancy
- Awareness of consequences is important
- A discrepancy between present behavior and important goals will motivate change
- The client should present the arguments for change
3. Avoid argumentation
- Arguments are counterproductive
- Defending breeds defensiveness
- Resistance is a signal to change strategies
- Labeling is unnecessary
4. Roll with resistance
- Momentum can be used to good advantage
- Perceptions can be shifted
- New perspectives are invited but not imposed
- The client is a valuable resource in finding solutions to problems
5. Support self-efficacy
- Belief in the possibility of change is an important motivator
- The client is responsible for choosing and carrying out personal change
- There is hope in the range of alternative approaches available
Brady S, Hiam CM, Seamann R, et al. Dual diagnosis: a treatment model for substance abuse and major mental illness. Community Mental Health J 1996; 32:573-578.
Miller WR, Rollnick S. Motivational Interviewing. New York: The Guilford Press, 1991
Minkoff K: Intervention strategies for dual diagnosis. Innovations and Research 1994; 2(4):11-17
Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Amer Psychologist 1992; 47(9):1102-1114.
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