This Issue:
Dual Disorders **Unapproved DRAFT March 14, 2001**

THE DCFS PERSPECTIVE
DCFS Article (Pending)
by _____, DCFS ________Division.

LITERATURE SUMMARIES

Severe Mental Illness and Substance Abuse
1. Integrated Treatment Is Best
2. Accurate Assessment Takes Time
3. Self-Help Groups Are Not for Everyone
4. AA Contact People Advise Special Groups
5. Recovery Challenges
6.Peer Counseling and Support Promote Recovery
7. Treatment May Not Reduce Stigma
8.Clinicians Undervalue Family Support

Anxiety, Depression and Substance Abuse
9. Cognitive-Behavioral Therapy Is Best

Minorities and Dual Disorders
10. Unequal Treatment
11. Treating African Americans

Women and Dual Disorders
12.Treatment Needs of Women
13. Problem Severity Can Lead to Dropout

Adolescents and Dual Disorders
14.SAMSHA Report Links Disorders

Mental Retardation and Dual Disorders
15.A Literature Review

Web Resources

DCFS Article     top
by - DCFS Division
Article pending...

1. Integrated Treatment Is Best     top

Drake, Robert E. and Mueser, Kim T. (2000). "Psychosocial Approaches to Dual Diagnosis." Schizophrenia Bulletin v26 n1 p105-118.

Drake, Robert E. and Fred C. Osher (1998). "Treating Substance Abuse in Patients With Severe Mental Illness." Pages 191-209 in Innovative Approaches for Difficult-to-Treat Populations. Washington, DC: American Psychiatric Press.

Drake, Robert E., Carolyn Mercer-McFadden, Kim R. Mueser, Gregory J. McHugo and Gary R. Bond (1998). "Review of Integrated Mental Health and Substance Abuse Treatment for Patients with Dual Disorders." Schizophrenia Bulletin v24 n4 p589-608.

The authors review literature on the prevalence and effects of dual diagnoses involving substance use disorders and severe mental illness and describe best treatment practices.

Severe Mental Illness Increases Vulnerability to Psychoactive Substances
Recent studies have found that approximately 50% of people with severe mental illness (schizophrenia, bipolar disorder and other severe mood disorders) develop substance use disorders. Substance abuse is most common among those who:

  • are young, male, single and less educated
  • have had conduct disorders and family histories of substance use disorders
  • are homeless or in jail
  • seek treatment in emergency rooms and other hospital settings.
Most people with severe mental illness find that using relatively small amounts of alcohol or other drugs negatively affects their psychiatric symptoms, behavior, relationships and ability to maintain housing and financial security. Many are more vulnerable to substance abuse as the result of poverty, poor social skills and lack of educational and vocational opportunities.

Some Aspects of Substance Abuse Are Universal
Both dually diagnosed individuals and those who only have substance use disorders:

  • most often abuse alcohol, followed by marijuana and cocaine
  • use psychoactive substances to relieve loneliness, social anxiety, boredom and insomnia
  • have problems related to loss of inhibition and instability in one or more life areas
  • often have chronic substance use disorders with recurrent relapses.

Dually Diagnosed People Have More Negative Life Experiences
More than one hundred studies indicate that people with dual disorders have higher rates of:

  • severe financial problems resulting from poor money management
  • unstable housing and homelessness
  • medication noncompliance, relapse and rehospitalization
  • sexually transmitted diseases
  • violence, legal problems and incarceration
  • depression and suicide
  • family burden.

Traditional Services Have Been Inadequate
Until recently there have been only two approaches to treating dually diagnosed individuals. Both are particularly unsuccessful with severely mentally ill individuals:

    Sequential treatment – Clients are expected to complete treatment in one system before being admitted to the other. However, most people with severe mental illness are quickly discharged from traditional substance abuse programs and do poorly in mental health programs that don’t address substance abuse. In some cases, individuals are denied access to both systems because neither is a good "fit."

    Parallel treatment – Clients must pursue simultaneous treatment in two independent systems and are stressed by trying to reconcile substantial differences in treatment philosophies and practices.

Integrated Treatment Provides Mental Health and Substance Abuse Treatment in One Setting
Integrated treatment provides mental health and substance abuse treatment in one setting. Other features of successful programs include:

  • recognition that recovery takes a long time and that many clients are not ready for abstinence-oriented treatment
  • treatment that is nonconfrontational, accommodates lack of motivation to change and provides long-term outreach, monitoring and support
  • motivational interventions to help clients see that substance abuse may prevent them from achieving their goals
  • skills training that teaches how to avoid substance abuse
  • medications prescribed to minimize abuse
  • selective rather than universal referral to 12-step and other support groups
  • clinicians who have modified previous beliefs about substance abuse and/or mental illnesses, learned new skills and are willing to experiment with new approaches.

Components of integrated treatment include:

    Case Management – With good case management, clients:

    • use more services
    • abuse substances less often
    • have fewer inpatient days and more time in stable remission.

    Case management should emphasize:

    • outreach and practical assistance
    • individualized education for clients
    • work with family members, employers, landlords and others who may be able to provide support.

    Substance Abuse Treatment:

    • Most programs focus first on education, harm reduction and increasing motivation to reduce substance use. Many include some form of cognitive-behavioral counseling.
    • Clients who attend special dual-diagnosis groups tend to have good outcomes.
    • Twelve-step and other self-help groups work best for people who have decided to abstain. Clinicians who refer clients to them should help them prepare for meetings and spend time afterward helping them understand what has happened.

    Close Monitoring:

    • Protective payeeships, residential monitoring, alcohol and drug screens, medication supervision, outpatient commitments and guardianships for medication are intended to increase safety, stability and treatment compliance.
    • Although their effectiveness has not been studied, clinical experience suggests that many individuals with severe mental illness need one or more forms of close monitoring during some phases of recovery.
    • Clients often fear the loss of independence that accompanies these measures but recognize that some external controls are necessary and helpful.

    Medication and Medication Monitoring:

    • Medication to control psychiatric symptoms is a crucial part of treatment, but little is known about the effectiveness of interventions such as education, skills training, long-acting injections, outpatient commitment and guardianships that are intended to increase medication compliance.
    • Typical antipsychotic medications may sometimes precipitate or aggravate substance abuse, while the newer drug clozapine may contribute to abuse reduction. Effects of other types of psychoactive medications on substance use are unclear or unknown.

    Housing:

    • Poor money management and other behaviors related to substance abuse make it hard for many individuals to maintain stable housing.
    • The limited research available suggests that outcomes are best when a range of staffed and supported housing options is offered as a part of integrated treatment.

    Rehabilitation:

    • To recover fully from dual disorders, individuals need opportunities to engage in new and more constructive relationships and activities.
    • Community-based education and employment programs that help people succeed at normal community roles show promise.
    • Day treatment, rehabilitation groups or sheltered work are less promising because it is harder to keep people involved in them over time, and clients often find them demeaning.

Interventions Should Be Based on Stage of Treatment
Treatment takes place in the following stages, although a person’s progress to stable recovery often involves much cycling back and forth between stages:

  • Engagement – Clients have no working relationship with clinicians and are not motivated to change their substance use. The focus is on establishing regular contact and helping to meet basic needs, such as housing and financial stability. In some cases, outreach must be persistent over a considerable period.
  • Persuasion – Regular contact is established, but clients are minimally invested in changing their substance use. The major focus is on achieving other goals while helping clients recognize how substance abuse contributes to their problems.
  • Active Treatment – Clients work on limiting substance use or achieving abstinence. Interventions depend on individual need and preference.
  • Relapse Prevention – The focus is on maintaining recovery and continuing personal growth. Relapses should be expected as a normal part of recovery and treated as learning experiences.

Maintaining Optimism is Vital
Successful dual disorder programs encourage hope in clients, family members and clinicians. People with dual disorders and their families are particularly vulnerable to demoralization, a common feature of adjusting to chronic illness that is often misunderstood and labeled as poor motivation. Clinicians must realize that motivation varies with a person’s level of confidence and hope for the future and typically improves when treatment is effective. Clinicians in turn need adequate training and organizational support in order to retain their own optimism and resilience.

2. Accurate Assessment Takes Time     top

Carey, Kate B. and Christopher J. Correia (1998). "Severe Mental Illness and Addictions: Assessment Considerations." Addictive Behaviors v23 n6 p735-748.

The authors summarize the research on effective assessment of substance use disorders in people with severe mental illness.

Substance Abuse Disorders Are Underdiagnosed in Mental Health Settings
Substance use disorders in people with severe mental illnesses have often been overlooked in mental health treatment settings because:

  • substance abuse can mimic symptoms of many other psychiatric disorders
  • clients may deny or minimize substance use early in treatment for a variety of reasons
  • clinicians are not always consistent in assessing for substance abuse and sometimes lack training in assessment techniques
  • more information about effective assessment is needed.

Use Multiple Information Sources for Provisional Diagnosis
Provisional diagnosis of a substance use disorder should be based on information from more than one of the following sources:

  • Self-report interviews and questionnaires – The reliability of self-reports varies. Individuals generally underreport substance use in crises, when they are intoxicated or when accurate reporting is likely to result in negative consequences but tend to report more accurately when they are stable and in treatment. The Dartmouth Assessment of Lifestyle Instrument (DALI) appears to be more reliable than instruments developed for the general population.
  • Collateral Information - Case managers and other clinicians who know clients well can be especially reliable sources. Studies have found that collaterals generally underreport substance abuse compared to self-reports by stable psychiatric outpatients.
  • Laboratory tests - Alcohol and drugs screens done in acute care and outpatient settings help identify some clients who might not otherwise report substance use. However, we do not know if laboratory test results are altered by use of psychoactive medications, and some use cannot be detected in this way.

Accurate Diagnosis May Take Considerable Time
Because diagnosis of dual disorders is complex, and adequate information is likely to become available only over time, a final diagnosis should not be based on a single interview. Depending on the complexity of an individual’s problems and how much opportunity there is to observe her/him during abstinence, accurate diagnosis can take weeks to years.

Functional Assessment Improves Interventions
Early intervention should include ongoing assessment of a client’s motivation to change. When an individual is ready to change, use information about situational, emotional and cognitive states that trigger substance use to develop strategies for avoiding high-risk situations. Try to understand the constructive aspects of substance use in clients’ lives in order to help them develop better ways of meeting their needs.

3. Self-Help Groups Are Not for Everyone     top

Noordsy, Douglas L., Brenda Schwab, Lindy Fox and Robert E. Drake (1996). "The Role of Self-Help Programs in the Rehabilitation of Persons with Severe Mental Illness and Substance Use Disorders." Community Mental Health Journal v32 n1 p71-81.

Referral to Alcoholics Anonymous (AA) and other self-help groups is often part of integrated treatment for dually diagnosed individuals, but people with severe mental illnesses do not always fare well in such groups. The authors summarize recent studies and clinical experience about how people with severe mental illness perceive self-help groups and how to make referrals to these groups.

Self-Help Has an Important but Limited Role in Treatment
Only a small percentage of people with severe mental illness and substance use disorders attend AA and similar self-help groups regularly, although most practitioners encourage their use. Regular attendees have found the following group features most attractive:

  • readily available support, including telephone contact with other members and sponsors
  • being able to choose if or when to talk in groups
  • ability to discuss problems other than substance abuse
  • the routine and structure provided by group attendance.
In addition, some people find the religious aspects of 12-step groups appealing, and others like using a "one day at a time" approach to abstinence. Some individuals who have difficulty using support groups early in treatment can use them after they have established an abstinence goal. In one small study participants preferred clinician-led dual disorder groups to self-help.

Support Groups Appeal Least to People with Schizophrenia
Support groups are least appealing to people with schizophrenia and individuals with poor social skills. Those who have dropped out or find it hard to attend regularly usually report one or more of the following:

  • trouble sitting still at meetings coupled with discomfort about leaving early
  • personal testimonies increase their desire to use substances, or they cannot relate to the stories because their losses have been different (e.g., many have never had spouses, jobs or significant possessions to lose)
  • delusions with religious content are aggravated by religious discussions
  • inability to socialize at meetings and/or feeling intimidated by the idea of accounting to a sponsor
  • other group members have been unsympathetic about their symptoms and/or poor social skills.

12-Step Jargon and Philosophy Can Be Alienating
Many clients react negatively to clinicians’ use of 12-step philosophy and jargon in treatment. Practitioners who challenge denial by using phrases like "Stinkin’ thinkin’" or "It’s your disease talking" fail to explore clients’ concerns about treatment and may send the message that their experience is not important. Another risk of pushing 12-step groups is that clients may agree to attend AA meetings to avoid discussing their use of other drugs or lack of participation in other phases of treatment.

Use These Guidelines for Referral
When introducing self-help is it best to:

  • remember that recovery and remission can occur without support group involvement
  • present self-help programs as one option that is helpful for many people and make alternatives available to people who decline
  • help clients sample meetings by going with them, introducing them to other group members and explaining procedures
  • encourage use of special dual disorder 12-step or cognitive-behavioral groups when they are available to improve member-group fit and ask recovering individuals to help orient new members
  • treat mental illness, addiction and underlying social skill deficits aggressively to increase clients’ ability to function independently in support groups.

4. Many AA Contact People Advise Special Groups for the Dually Diagnosed     top

Meissen, Greg, Thomas J. Powell, Scott A. Wituk, Kathy Girrens and Shirley Arteaga (1999). "Attitudes of AA Contact Persons Toward Group Participation by Persons With a Mental Illness." Psychiatric Services v50 n8 p1079-1081.

Midwestern AA Contact People Were Surveyed
The authors report results of a 1996 survey that investigated attitudes of 125 Alcoholics Anonymous contact persons in the Midwest toward participation of dually diagnosed people in AA.

Most Had Positive Attitudes Toward People with Mental Illness but Advised Special Groups

  • More than 85 % of the respondents agreed or strongly agreed that dually diagnosed people could be valuable group members.
  • 92.8% believed that people with dual disorders should continue to take medications.
  • 69.6% thought that dually diagnosed individuals would not fit well into their particular groups.
  • 54% believed it would be better if they attended special dual disorder groups.

Because dual disorder groups (See Web Resources) are not always available, dually diagnosed individuals who are interested in attending AA may have to "shop" for a regular group that is a good fit. Clinicians should provide support during this process by preparing clients for what they may encounter, assisting with problem solving and offering to attend groups with them until they are prepared to attend alone.

5. Recovering Individuals Identify Challenges     top

Laudet, Alexandre B., Stephen Magura, Howard S. Vogel and Edward Knight (2000). "Recovery Challenges Among Dually Diagnosed Individuals." Journal of Substance Abuse Treatment v18 n4 p321-329.

The authors report results of a study that asked 310 members of Double Trouble in Recovery (DTR) support groups in New York City to rate the difficulty of basic recovery activities. Participants were predominantly male (72%), African American (58%), Hispanic (16%) and white (25%). Ages ranged from 20 to 63, with the median at 39.

Feelings, Finances and Sobriety Are Difficult
Recovery activities rated hardest by the majority of participants, from most to least difficult, were:

    Coping with feelings and inner conflicts – Clients’ emotions may have been masked by their previous substance abuse and may be particularly hard to deal with because of the emotion regulation deficits that accompany mental illness. The shame, regret and guilt that are often aroused during recovery can add to emotional overload. Emotion management is particularly important and difficult for people with histories of childhood abuse. Inability to cope with painful or uncomfortable feelings is strongly linked with return to substance abuse.

    Finding work, working and dealing with financial problems are significant and difficult issues for a number of reasons:

    • disability benefits do not provide a satisfactory standard of living
    • unemployment is stigmatizing, often leaves individuals without resources for constructively structuring their time and creates feelings of low self-worth and incompetence
    • recovering people may have little or no work experience or skills for finding and keeping employment
    • symptoms and medication side effects sometimes make successful employment more difficult
    • the disability system itself presents obstacles to employment
    • stigma may increase the challenge of finding work.

    Maintaining sobriety – Half of the participants found maintaining sobriety very difficult, while only one quarter rated coping with mental illness equally difficult. The explanation for this may be that the challenges of achieving and maintaining abstinence were less familiar, so participants had developed fewer coping skills.

Asking for Help, Listening and Support Groups Are Easier
Three recovery activities crucial to development of new coping skills were easier for most participants:

  • asking for help and support
  • being open-minded and listening
  • working a program of recovery such as DTR (rated least difficult by most).
This supports previous findings that self-help has a more positive impact on self-concept and interpersonal satisfaction than professional services.

6. Peer Counseling and Support Promote Recovery     top

Klein, Amelia Rocco, Ram A. Cnaan and Jeanie Whitecraft (1998). "Significance of Peer Social Support with Dually Diagnosed Clients: Findings from a Pilot Study." Research on Social Work Practice v8 n5 p529-551.

Peer Counseling and Support Promote Recovery From Severe Mental Illness
People with severe mental illnesses have better treatment outcomes and report greater life satisfaction when they receive case management services from clinicians who have had psychiatric disorders. Peer support is also beneficial, resulting in higher levels of general satisfaction, increased self-esteem and reduced loneliness.

Pilot Study Investigated Effectiveness of Peer Counseling with Dually Diagnosed Individuals
The authors were the first to investigate the effects of peer counseling and support on treatment outcomes for dually diagnosed individuals with severe mental illnesses. Their results are encouraging.

The six-month study was conducted at John F. Kennedy Mental Health-Mental Retardation Center in Philadelphia with 61 participants who ranged in age from 26 to 59. Twenty-six percent were female, 76% African American, 19% Caucasian and 5% Latino. Fifty-one clients received standard dual disorder services, and 10 received additional services from the JFK Center’s Friend’s Connection program. All had stable relationships with their intensive case managers.

Friend’s Connection Normalizes Recovery Activities
Friend’s Connection hires people who are in recovery from addiction, psychiatric illness or dual disorders to serve as peer counselors, recovery "coaches" and role models to assigned "friends" with dual disorders. Peer counselors receive training in various aspects of mental health counseling and engage in frank discussion of recovery issues, social activities and 12-step participation with their clients. Program participants are thus able to learn daily living and social skills in the community rather than in artificial and more costly institutional settings.

Peer Counseling Improved Outcomes and Was Cost Effective
At the end of the six-month study, the group involved with Friend’s Connection:

  • had only one (10% prevalence) crisis event (suicide attempts, disturbances at home, attacks on others, etc.) compared to sixteen (31% prevalence) for the group receiving standard services
  • had no hospitalizations, compared to 1,282 inpatient days (twenty-five per person) for the standard services group
  • functioned better and reported more satisfaction with their lives
  • had less substance use than the standard service group.

The total cost of Friend’s Connection services was $30,000, and findings suggest that they may have prevented nearly $250,000 in hospitalization costs among the study group members. Clearly, adding peer counseling to intensive case management services can be very cost effective and should be done more frequently.

7. Treatment May Not Reduce Stigma     top

Link, Bruce G., Elmer L. Struening, Michael Rahav, Jo C. Phelan and Larry Nuttbrock (1997). "On Stigma and Its Consequences: Evidence from a Longitudinal Study of Men with Dual Diagnosis of Mental Illness and Substance Abuse." Journal of Health and Social Behavior v38 n2 p177-190.

Treatment Reduced Symptoms but not Stigma
The negative effects of stigma on self-concept and life satisfaction have been well documented, but we do not know if effective treatment can counter these effects. The authors report results of a study in which reduction of symptoms did not significantly reduce the consequences of stigma.

Participants were 84 men who completed a year of treatment for dual disorders, either in a therapeutic community (48) or community residence (36) in New York City. Their mean age was 34. Sixty-three percent were African American, 23% Latino and 14% white or from another ethnic/racial background. Fifty-eight percent had psychotic disorders, primarily schizophrenia, 14% had bipolar disorder or major depression, and the remainder had other diagnoses.

All the men had substantial reduction in symptoms of mental illness and substance abuse during their year in treatment, but they experienced stigma and related depression just as strongly as when treatment began.

Stigma May Reduce Treatment Benefits
We must find ways to more effectively reduce stigma. Persistent experience of stigma may play a role in the known tendency for treatment benefits to diminish over time.

8. Clinicians Undervalue Family Support     top

Clark, Robin (1996). "Family Support for Persons with Dual Disorders." Pages 65-78 in Dual Diagnosis of Major Mental Illness and Substance Abuse, Volume 2: Recent Research and Clinical Implications. New Directions for Mental Health Services, Number 70. San Francisco: Jossey-Bass.

The author reviews literature on the importance of family support to dually diagnosed individuals.

Treatment Providers Often Underestimate Family Support
Recent research has found that families supply much direct care and financial support to dually diagnosed relatives. For example:

  • A 1994 study found that parents provided services that would have cost almost $14,000 per client if supplied by case managers or home health aides.
  • Without family support, many clients lack housing and adequate nutrition. Absence of family support is the factor most strongly associated with homelessness, and dually diagnosed people who have negative family relationships are most vulnerable to being homeless.

Unfortunately, clinicians are often unaware of the vital roles played by family members. It is possible that clients prefer to keep such matters private or that clinicians are trained to focus on the negative aspects of family relationships.

Clinicians Should Initiate Better Working Relationships
Little is known about how treatment affects the family relationships of dually diagnosed people or what roles their families play in recovery. However, there is evidence that everyone can benefit from more cooperative working relationships. Studies have found that:

  • Family members are stressed by providing support, but clinicians may not help to reduce this stress.
  • People with schizophrenia whose families receive therapy or education have fewer psychiatric symptoms and relapses.
  • Families often do not understand the relationship between substance abuse and problematic behaviors of mentally ill relatives and need more information.
  • Clinicians tend to blame families for being overinvolved or having difficult relationships with mentally ill relatives. However, there is no evidence that families who appear emotionally overinvolved give too much direct support or that those who give a great deal of support do so inappropriately. It is better to see relationship problems as normal and all family members responsible for finding solutions.
  • Family members can provide helpful information, but they often feel frustrated or disappointed about the relationships they have with their relatives’ clinicians. Professionals should express appreciation for family members’ knowledge and contributions and offer useful services.
  • Specialized family services may be more effective than generic education and support groups that try to deal with all family members and diagnoses.

9. Cognitive Behavioral Therapy Is Most Effective for Substance Use Disorders, Anxiety and Depression     top

Horvath, Arthur T. (1997). "Psychotherapy of Substance Abuse with Comorbidity." Pages 253-267 in Treatment Strategies for Patients with Comorbidity. New York: John Wiley & Sons.

From 20% to 66% of people in the U.S. with clinical anxiety or depression also have substance use disorders. The author presents guidelines for assessment and treatment of these dual disorders based on research and clinical experience.

Screening and Assessment Guidelines
During screening and assessment it is important to:

  • ask about addictive behaviors in general (compulsive eating, sexual behavior, gambling, overspending, substance abuse etc.) because they tend to occur in clusters
  • avoid conveying expectations about acceptable levels of substance use or other addictive behaviors, both to encourage accurate reporting and to avoid communicating negative judgements
  • assess the types and amounts of substances used, circumstances that lead to use, the person’s level of motivation to reduce or abstain from use and the potential need for medically supervised detoxification
  • assess and acknowledge the benefits as well as the drawbacks of substance abuse
  • screen for cognitive impairments that may affect the course of therapy
  • start identifying relationships between substance abuse and psychiatric symptoms, as well as the client’s underlying assumptions about both
  • assess for the risk of suicide, which is particularly high among these clients.

Effective Treatment Takes Time
Individuals with these dual disorders may have difficulty understanding and expressing their feelings, thoughts and goals. It may take a great deal of time to help them express themselves and learn to deal with complex problems. If a client has cognitive impairments, it is important to slow the pace of therapy, present information simply and clearly and to elicit frequent responses to make sure he or she understands.

Demanding Abstinence Is Counterproductive
Many people refuse abstinence at first but later may successfully decrease their use or achieve abstinence for long periods. Demanding abstinence, on the other hand, may make them drop out of treatment.

Teach Reduced Consumption
Teach clients to reward themselves for reducing their consumption and to see failure as an opportunity to learn. Cutting consumption in half is a realistic first goal. Clients who are unable to drink or use moderately will often see the wisdom of abstinence. In the case of illicit drugs, it is important to express clear concern about the potential consequences of illegal behavior and encourage clients to stop using as quickly as they can.

Studies have found that moderation training is effective for many people with alcohol use disorders. Ultimate limits should be no more than 7 drinks weekly for women and 12 for men.

Cognitive-Behavioral Therapy is Most Effective
Cognitive behavioral therapy is the most effective treatment for substance use, anxiety and depressive disorders. This treatment identifies and challenges irrational beliefs that support substance abuse and dysfunctional emotional states. It encourages more adaptive thinking and teaches a wide range of coping behaviors and other skills that support recovery.

Cognitive-Behavioral Support Groups are Congruent with Therapy
There are a growing number of abstinence- or moderation-oriented support groups with a cognitive behavioral rather than twelve-step focus (See Web Resources for more information). They include:

  • Rational Recovery
  • S.M.A.R.T. Recovery
  • Women for Sobriety and
  • Moderation Management

10. Minority Clients Received Less Support     top

Jerrell, Jeanette M. and John L Wilson (1997)."Ethnic Differences in the Treatment of Dual Mental and Substance Disorders: A Preliminary Analysis." Journal of Substance Abuse Treatment v14 n2 p133-140.

Study Was the First to Report Outcomes for Minority Clients
The authors’ study is the first to report outcomes for minority clients in dual disorder treatment.

Eighty-seven percent of the 40 minority clients who participated were male, and over half were between 18 and 33 years of age. Twenty-six were Latino, 8 African American, 3 Asian American and 3 Native American.

Minority Clients Were Perceived As Lower Functioning but Received Fewer Services
No significant differences were found between ethnic minority and white participants in terms of age, gender, diagnosis, number of days in twenty-four-hour care in the year preceding the study, symptoms, psychosocial functioning or alcohol/drug abuse severity. However, minority clients rated themselves and were assessed by clinicians as lower functioning. Despite this, they received fewer supportive services - case management, outpatient and medication visits, number of days in supported housing and day treatment - than whites.

Cultural Misunderstandings and Negative Preconceptions Affected Clinical Judgment, Services, and Community Supports
To some degree, clinical impressions of lower functioning and more severe and chronic symptoms in minority clients were caused by cross-cultural misperceptions. Minority clients also commonly experienced the following inequities and disadvantages:

  • Younger clients, particularly African Americans, were more likely to enter treatment involuntarily as the result of criminal justice involvement, typically for misdemeanors or because their families reported them to police to obtain services. Forced treatment made clients wary of seeking treatment on their own, and most relapsed very quickly after mandatory treatment ended. Clinicians tended to view these clients as malingering, antisocial or noncompliant.
  • It was hard to find residential placements for young men with more acute symptoms because they were often viewed as dangerous, even when they had no history of acting out.
  • Limited education and lack of work skills prevented admission to housing programs that required residents to seek work immediately.
  • Many prospective employers viewed younger males from ethnic minorities as "bad risks."
  • Many minority clients had inadequate social support systems. Families and friends often lacked information about psychiatric and substance use disorders, believed that clients were willfully misbehaving and involved police during crises.
  • Minority clients found less acceptance in community 12-step groups, and clinicians had extreme difficulty finding willing sponsors for those who were young.
  • Younger minority clients were more likely to have no source of income. Their benefits were sometimes terminated for noncompliance with reporting requirements or because they had no approved residence.
  • Shelters would not accept dually diagnosed single women; therefore, those without support from family or friends were extremely vulnerable to homelessness, street crime and/or abusive partners.
Consequently, minority group members often had nothing to help motivate them to reduce or end substance abuse.

Programs Should Make These Changes
The following changes are needed to improve treatment outcomes for minority clients:

  • Clinical and support staff should receive cultural sensitivity training and ongoing consultation. Interventions should be culturally appropriate, and clients and clinicians should be ethnically matched whenever possible.
  • Treatment programs must provide more financial, social, educational and vocational supports. Smaller caseloads would allow staff more time to address clients’ needs with prospective landlords, 12-step sponsors, family members, vocational rehabilitation programs, etc.
  • Clinicians should be available to divert clients with psychiatric and substance use disorders out of the criminal justice system and into treatment.

11. Treating African Americans     top

Baker, F.M. (1999). "Issues in the Psychiatric Treatment of African Americans." Psychiatric Services v50 n3 p362-368.

Schizophrenia Is Overdiagnosed
Studies suggest that schizophrenia is overdiagnosed in African American patients but mood disorders, such as depression and bipolar disorder, sometimes go undetected. Clinician bias and misinterpretation of hallucinations that often accompany depression among African Americans are likely causes.

Misdiagnosis results in inappropriate and ineffective treatment, including unnecessary exposure to risk of tardive dyskinesia, an irreversible movement disorder sometimes caused by medications used to treat schizophrenia.

African Americans May Respond Differently to Psychoactive Medications
Recent studies suggest that African Americans respond differently to common medications. They may:

  • respond weakly to beta blockers used as antianxiety medications
  • have stronger and more rapid responses to tricylic antidepressants than whites
  • be less likely than whites to respond to fluoxetine, the generic name for the antidepressant Prozac
  • have much greater sensitivity than other racial groups to some antianxiety medications
  • need less lithium to control symptoms of mania.

Treatment Should Be Culturally Sensitive
Clinicians who work with African Americans should:

  • reconsider old diagnoses
  • ensure that the assessment tools they use have been found reliable for use with African Americans
  • be aware that probing interviews and neutral listening postures may be interpreted as rejection
  • address experiences of racism and their effects on identity and self-determination
  • explore spiritual beliefs and practices
  • discuss beliefs and feelings clients may have as the result of reading antipsychiatry l iterature directed to the African American community.

12. Dually Diagnosed Women Have Gender-Specific Problems, Needs and Strengths     top

Alexander, Mary Jane (1996). "Women with Co-Occurring Addictive and Mental Disorders: An Emerging Profile of Vulnerability." American Journal of Orthopsychiatry v66 n1 p61-70.

Studies Differ About Gender Distribution of Dual Disorders
It is unclear whether men and women have the same rate of dual disorders because population distribution studies have had conflicting results.

Women Experience More Serious Physical Consequences of Substance Abuse
We do know that women suffer more serious physical consequences of substance abuse. For example:

  • Alcohol is the third leading cause of death among women aged 35 to 55 years.
  • Women experience adverse physical effects of drinking more quickly then men and at lower consumption rates, including more rapid onset of liver disease and more frequent death from cirrhosis.
  • Women substance abusers have increased risk of breast cancer, absence of menstrual periods, spontaneous second trimester abortions and sexually transmitted diseases.

Dually Diagnosed Women Experience More Victimization and Less Social Support
It is important to include questions about past and current victimization in assessments of all women with substance use disorders and/or severe mental illness because:

  • Studies indicate that women with substance use disorders are more likely to have histories of childhood sexual, physical and emotional abuse and to be adult victims of violent crimes than other women or men.
  • There is growing evidence that women with severe mental illness also have higher rates of childhood and adult victimization.
  • Those who are dually diagnosed have experienced more victimization than those with severe mental illness alone.
  • Addiction is the most significant risk factor for homelessness and loss of family support among women who have schizophrenia.

Women Are Less Likely to Seek Substance Abuse Treatment or to Have Substance Use Disorders Diagnosed
Fewer women than men enter substance abuse treatment, and more of them drop out. When women do enter addiction programs, their symptoms are likely to be severe. Women are more apt to obtain treatment in primary health care and mental health settings, where their substance abuse problems may go undetected or unaddressed.

Be alert for lethargy, fatigue, frequent illness and neglect or deterioration of physical appearance. They may be signs of alcohol problems in women but are not included in standard assessment instruments.

Women with Schizophrenia Have Assets That Support Recovery
Dually diagnosed women who enter treatment are more likely than men to be poor. They also have less education and fewer job skills. However, compared to schizophrenic men, women with schizophrenia have the following strengths and resources to support recovery:

  • fewer negative symptoms, greater compliance with and responsiveness to medication and psychotherapy and a tendency to recover with fewer relapses
  • better social and vocational skills and higher rates of marriage and employment
  • better pre-illness social functioning.

Dual Disorder Treatment for Women Should Address These Needs
Treatment programs for dually diagnosed women must be prepared to meet needs for:

  • health care, including education about healthy pregnancy, birth control and preventing sexually transmitted diseases
  • case management
  • community-based residential facilities that provide privacy and allow the unusual sleep times sometimes needed by individuals who have been traumatized
  • child care arrangements that facilitate treatment
  • parenting skills education
  • help in dealing with role loss, including loss of child custody when this occurs
  • therapy and education that will help end current victimization
  • education about stress management, structuring leisure time to maintain abstinence, and forming supportive relationships
  • woman-only treatment and support groups to help deal with abuse issues and develop independence and personal effectiveness
  • peer support to help with relapse prevention.

13. Problem Severity Can Lead to Dropout     top

Brown, Vivian B., Lisa A. Melchior and G.J. Huba (1999). "Level of Burden Among Women Diagnosed with Severe Mental Illness and Substance Abuse." Journal of Psychoactive Drugs v31 n1 p31-40.

Study Participants Were Involved in Innovative Treatment
The authors evaluated the residential treatment program at PROTOTYPES in Los Angeles. PROTOTYPES offers outpatient, day and residential treatment specifically designed for addicted and dually diagnosed women.

Time required to complete residential treatment varies from 6 to 18 months. Major treatment goals include:

  • personal empowerment
  • learning to lead a drug-free life
  • developing improved daily living skills and the ability to hold a job and
  • becoming an effective parent.

Women with Severe Mental Illness, Positive HIV Status and High Levels of Burden Were More Likely to Drop Out
Women with severe mental illness, positive HIV status and high levels of burden (histories of physical or sexual abuse, homelessness, multiple health problems, use of several drugs) were most likely to leave treatment prematurely, and those who used methamphetamines generally remained longer. Other diagnoses and problems were not associated with dropping out or longer-than-average stays.

Results suggest that women with posttraumatic stress disorder and borderline personality disorder, who often do poorly in programs developed for men, can do well in treatment specifically designed for women.

Longer Stays Were More Beneficial
Women who remained in treatment six months or longer, compared to those who stayed for shorter periods, were:

  • 30 times more likely to be considered ready for discharge by clinicians
  • 20 times more likely to assess themselves positively
  • 6 times more likely to be abstinent
  • 5 times more likely to have plans for employment or education
  • 4 times more likely to have a safe place to live
  • less likely to leave treatment against advice or to be discharged because of noncompliance, to have significant emotional and/or interpersonal problems at termination or to lack direction.

Women with Severe Mental Illness May Benefit From Special Supports
Women with severe mental illnesses who remained in treatment were just as likely as other participants to do well. Those who dropped out early may have been overwhelmed by the demands of the residential treatment setting – interacting with many new people, complying with program rules and procedures and attempting major behavioral changes.

These services can help women adapt:

  • stabilization on psychoactive medications
  • treatment readiness groups
  • preadmission visits that include time to speak with current residents
  • special support from referring and residential program clinicians during intake and early treatment.

14. SAMSHA Report Links Adolescent Mental Health Problems and Substance Use     top

U.S. Substance Abuse and Mental Health Services Administration (1999). "The Relationship Between Mental Health and Substance Abuse Among Adolescents." On the Web at http://www.samhsa.gov/oas/NHSDA/A-9/comorb3c.htm#TopOfPage

These Links Have Been Identified
The number of adolescents with dual disorders is unclear. Estimates range from 22% to 82%, depending on the population surveyed. However, research does show that:

  • Youth who are hyperactive or exhibit antisocial behaviors are more likely to use alcohol or other drugs.
  • There is more tobacco use among high school students with behavior problems.
  • There are childhood indicators of emotional disturbance in people who later became heavy marijuana users.

SAMSHA Report Provides Further Evidence That Problems Occur Together
This lengthy report, prepared for SAMSHA by the National Opinion Research Center, summarizes data collected during the 1994-1996 National Household Survey on Drug Abuse. The survey included a random sample of 13,381 adolescents aged 12 to 17.

Major study findings include:

  • 13% of the youth experienced withdrawal, somatic problems, anxiety and depression. Youth who had severe emotional problems of this type were nearly four time more likely than those who did not to be dependent on alcohol or illicit drugs.
  • 17% of the youth showed delinquent or aggressive behaviors. Substance dependence was more than seven times more likely among youth with serious delinquent or aggressive behaviors than among those with few such behaviors.

Stealing, using obscene language, skipping school, hanging around with others who get into trouble and running away were behaviors most highly associated with substance use, as was "feeling confused or in a fog." On the other hand, youth who used substances were less likely to report being teased, preferring younger friends, acting too young for their age, or overdependence on adults.

More Research is Needed to Identify High Risk Youth and Effective Interventions
Further research, particularly longitudinal studies, is needed to clarify the complex relationships between mental health problems and substance use in adolescence. Future studies may also make it possible to identify high-risk youth and develop more effective interventions.

15. Mental Retardation and Substance Use Disorders     top

Christian, LeeAnn and Alan Polling (1997). "Drug Abuse in Persons With Mental Retardation: A Review." American Journal on Mental Retardation v102 n2 p126-136.

This article reviews the sparse literature on diagnosis and treatment of people with mental retardation and substance use disorders.

People with Mental Retardation May Have Unique Vulnerability
People with mental retardation are vulnerable to the same risk factors for substance use disorders that affect the general population and may have unique vulnerabilities. For example, inadequate self-regulation, which is a predictor for substance abuse in general, is a particular problem for mentally retarded individuals. However, no studies have attempted to identify risk factors that are specific to this population.

Harmful Effects Have Been Documented
There is insufficient data about how often and how seriously people with mental retardation are negatively affected by substance use, but it does have harmful results, including:

  • job-related problems - arriving at work late, absenteeism, drinking on the job, problems with co-workers and suspensions for drinking
  • relationship problems - physical fights, arguments, having to leave home and loss of romantic partners and friends.
  • warnings and arrests for disorderly conduct, driving while intoxicated and public intoxication
  • medical problems, such as seizures, substantially impaired motor functioning and adverse interactions with medication.

Substance Use Disorders and Retardation Can Be Confused
Diagnosis of substance use disorders among people with mental retardation can be particularly difficult because:

  • signs of substance abuse and intoxication - irritability, impaired skills, socially inappropriate behaviors, slurred speech, unsteady gait and poor coordination - are often found among mentally retarded people who do not abuse substances
  • some people with developmental delays cannot accurately report substance use
  • service providers may be unwilling to further stigmatize mentally retarded individuals with other labels and thus be slow to acknowledge substance abuse.

Appropriate Treatment May Be Difficult to Find
Some substance abuse treatment programs exclude mentally retarded people, and developmental disability programs may be reluctant to accept clients who have substance use disorders. Clinicians are rarely trained to deal with both disorders. Other treatment barriers include:

  • cognitive and social skill impairments that can make it difficult for mentally retarded individuals to participate in groups
  • unwillingness of some substance abuse programs to treat people who must take medication
  • the expense of private substance abuse treatment and long waiting lists for publicly funded programs.

SARDI Program Provides Resources
Substance abuse prevention and education programs for mentally retarded individuals have received even less attention than treatment. One notable exception is the Substance Abuse Resources for Disabled Individuals (SARDI) Program (see Web Resources), a demonstration project developed at Wright State University School of Medicine to educate professionals about substance abuse risks among the mentally retarded and other people with disabilities.

These Modifications May Improve Treatment
The relatively few programs that provide substance abuse treatment for people with mental retardation usually incorporate one or more of the following features, although their effectiveness has not been evaluated:

  • frequent reinforcement for appropriate behavior
  • simplified written materials supplemented with pictures, videos and one-to-one oral review
  • extended periods of active treatment
  • individualized aftercare and relapse prevention programs
  • adequate social support for sobriety following treatment.

Web Resources     top

Professional Resources
Centre for Addiction and Mental Health
The Centre’s mission is to improve understanding and treatment of psychiatric and substance use disorders via research. Among its offerings are full text articles from the Journal of Addiction and Mental Health, position and best practice papers, and a catalog of print resources for clinicians.
http://www.camh.net/

Dual Diagnosis Web Site
Maintained by Kathleen Sciacca, M.A., this site offers a glossary of basic definitions, online articles, a professional listserv and a directory of treatment centers.
http://users.erols.com/ksciacca/

Inpatient Programs for Special Populations
See the Addiction Resource Guide at this Web site for a list of addictions programs. The programs are indexed by the populations served, including people with psychiatric disorders, mental retardation and other developmental disabilities.
http://www.addictionresourceguide.com/specpop/special.html

Peer Educator’s Project, Massachusetts Behavioral Health Partnership
This project is an innovative peer support program under development by two large providers of mental health and dual disorder services in Massachusetts.
http://www.masspartnership.com/member/bestpractices.htm

Prototypes Centers for Innovation in Health, Mental Health and Social Services
The Centers have developed the PROTOTYPES addictions programs (article on page 11) and are involved in ongoing research to improve services for women with multiple needs. Here you will find information about the Centers’ services and publications.
http://www.prototypes.org/index.html

SARDI (Substance Abuse Resources and Disability Issues) Program
The SARDI Program at Wright State University offers a variety of research-based electronic and print resources to improve work with clients affected by drugs and disabilities.
http://www.med.wright.edu/citar/sardi/

Resources for Self-Help and Support
Dual Recovery Anonymous (DRA)
DRA is a 12-step self-help organization for people with dual disorders. This site provides information about the history and philosophy of DRA and a list of groups by state.
http://draonline.org/

Moderation Management
This support group encourages moderate drinking for those who can attain this goal and abstinence for those who cannot. Look here for a program description and other online resources.
http://www.moderation.org/

Rational Recovery (RR)
Rational Recovery was the first abstinence-oriented program to use the principles of cognitive-behavioral therapy to promote recovery. Find RR’s online Addictive Voice Recognition Technique and other resources here. This organization is actively opposed to Alcoholics Anonymous and does not encourage support group participation of any kind, believing that it fosters unhealthy dependence.
http://www.rational.org/

SMART Recovery
SMART Recovery also offers abstinence-oriented support groups whose members use principles of cognitive-behavioral therapy to overcome drinking and using problems. Among other resources, this site offers an online meeting, discussion of SMART Recovery principles and practices and a list of meetings by state.
http://smartrecovery.org/

Women for Sobriety
Women for Sobriety provides self-help for women with addictive disorders. It offers a "New Life Program" to promote personal empowerment and positive change, a Pen Pal program and other resources.
http://www.womenforsobriety.org/