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Treatment of Patients With Psychiatric and Psychoactive Substance Abuse Disorders

Fred C. Osher, M.D. Lial L. Kofoed, M.D.

The treatment ofindividuals with coexisting psychoactive substance

abuse and severepsychiatric disor- ders requires an integration of

principles from the mental health

and chemical dependency fields. The authors outline a conceptual

model for treating dually diag-

nosedpatients that consists offour treatment phases-engagement, persuasion, active (or primary) treatment, and relapse prevention. The components of these phases

include case management, group therapy, psychopharmacology,

toxicologic screening, detoxifica- tion,family involvement, and par-

ticipation in self-help groups. Due to the high morbidity and mor-

tality associated with dual diag- noses, the authors encourage the development, implementation,

and scientific evaluation of in- tegrated treatment models tar- geted toward this population.

The consequences ofcoexisting psy- chiatric and psychoactive substance use disorders can be devastating, yet few studies have assessed the treat- ment ofthis dually diagnosed patient population. Compared with either mentally ill or chemically dependent patients, dually diagnosed patients demonstrate increased rates of hos- pitalization ( 1), utilization of acute care services (2), housing instability and homelessness (3-5), violent and criminal behavior ( 1 ,6), and suicidal behavior (3,7).

Poor medication compliance (3,8) and poor response to tradition-

al substance abuse treatment (9,10) have also been associated with having dual disorders. Despite, and perhaps because of, the severe ef- fects of such comorbidity, dually diagnosed patients are often ex- cluded from treatment settings.

Dual diagnosis patients are het- erogeneous in the psychiatric diag- noses they receive (1 1, 12), the sub- stances they abuse (6,1 1), and the degree of dysfunction they show (13). Both symptom severity (10) and psychiatric diagnosis (14,15) have been found to predict treat- ment response of patients with sub- stance use disorders.

Among nonpsychotic patients with dual diagnoses, a diagnosis of personality disorder, especially anti- social personality disorder, has been associated with adverse outcome (14-17). Improved outcome for

1026 October 1989 Vol. 40 No. 10 Hospital and Community Psychiatry

these patients when significant symptoms of anxiety or depression are present has resulted from adding psychotherapy to substance abuse counseling (16). The treatment of patients with primary affective and anxiety disorders and substance use disorders remains controversial. Recent reviews by Galanter and as- sociates ( 1 8) and Bloom and as- sociates (19) address issues in the treatment of nonpsychotic patients within the dual-diagnosis popula- tion.

This paper reflects our exper- ience treating patients with severe, chronic, or recurrent axis I psychiat- tic disorders, including schizophren- ia and bipolar affective disorder, who also abuse psychoactive sub- stances. We outline a conceptual model for treating such patients that emphasizes four phases of treat- ment: engagement, persuasion, ac- tive (or primary) treatment, and relapse prevention. The treatment recommendations represent a syn- thesis of our clinical experience and the scant available literature. We en- courage clinical research to further validate this model and other ap- proaches to integrated treatment of patients with psychiatric and sub- stance abuse disorders.

Treatment overview Integrated treatment. Treatment approaches for dually diagnosed pa- tients thatprovide mental health and substance abuse interventions se-

Dr. Osher is staff psychiatrist at West Central Community Mental

Health Services in Hanover, New Hampshire. Dr. Kofoed is direc- tor of outpatient services at the Veterans Administration Medi- cal Center in White River Junc- tion, Vermont. Dr. Osher is also assistantprofessor andDr. Kofoed

is associate professor in the department ofpsychiatry at Dart- mouth Medical School in Han- over. Address correspondence to Dr. Osher at 18 Bailey Avenue, Claremont, New Hampshire 03743. This paper is part of a spe- cia! section on patients with dual diagnoses of mental illness and substance abuse.

quentially result in a sort of “Ping- Pong therapy” that maygive patients conflicting messages and little chance of compliance with both treatment plans. Parallel treatment ofboth disorders in separate systems has similar limitations.

We advocate the integration of existing mental health and chemical dependency approaches for treating dually diagnosed patients (20). Such approaches have demonstrated some efficacy (1 7,2 1). They require

ongoing attention to both disorders and a synthesis of treatment prin-

ciples. They also allow clinicians to monitor multiple problems and prioritize treatment goals. In devel- oping the model we present in this paper, our aim was to respond to the needs ofpatients with severe psychi- atric illnesses. Therefore, the model we describe integrates substance abuse treatment into a mental health

agency setting. Treatment setting. The rela-

tive value ofinpatient and outpatient treatment settings for dually diag- nosed patients remains to be deter- mined, a state of affairs also largely true for treatment of primary sub- stance abusers. Outpatient treat- ment forvery ill dually diagnosed pa- tients has been described (17,2 1).

However, assessment of the con- tributions of psychiatric illness and substance abuse to patients’ clinical presentations may require observa- iion within a controlled environ- ment. Access to brief psychiatric hospitalization is therefore essential.

Appropriate goals for such hospital- izations include detoxification, diag- nostic clarification, stabilization of the patient, and adjustment of medications. In addition, hospital- ization provides an opportunity to persuade the patient to accept reha- bilitative treatment (22,2 3).

Substances ofabuse. Except in programs focused on special modal- ities such as methadone mainte- nance, primary abusers of alcohol and of a variety of drugs can be treated in the same program with lit- tIe reduction in efficacy (24). On the other hand, one study ofdually diag- nosed patients found worse out- comes among patients who abused alcohol than among patients who

abused drugs when the two groups were treated together, although these patients differed on other van- ables besides substance of abuse (17). Further research into the need

for substance-specific treatment programming is required.

Polysubstance abuse is frequently reported in the dual-diagnosis pop- ulation (3,20,25). Clinicians work- ing with this population must be prepared to provide treatment for the abuse ofa wide range of psycho- active substances.

Treatment phases Patients joining an integrated treat- ment program are likely to be in dif- ferent phases ofillness and recovery, given the chronic relapsing course of severe psychiatric and addictive dis- orders, the variation in individuals’ ability to form treatment relation- ships (1 7,26), and differences in pre- vious exposure to treatment. Treat- ment goals should reflect this van- ability. For instance, abstinence is not a feasible goal until the patient has acknowledged substance abuse as a problem. Relapse prevention cannot be taught before a period of sobriety.

The four phases described below differentiate patients on the basis of their commitment to substance abuse treatment, yet are also depen- dent on the management and stabil- ization oftheir psychiatric disorder.

Engagement Dually diagnosed individuals must first be attracted to treatment pro- grams. Engagement denotes the pro- cess of convincing patients that the mental health agency or provider has something desirable to offer them. Enticements may include help in avoiding legal penalties or in obtain- ing food, housing, clothing, access to entidement programs, or relief from distressing symptoms. Socialization, recreation, and vocational oppor- tunities may also provide incentives for participation in treatment. Iso- lated on homeless patients often re- quire assertive outreach, help with basic needs, and support during crises (27).

Engagement can also be accom- plished indirectly by staff liaison with family members or coercively

Hospital and Community Psychiatry October 1989 Vol. 40 No. 10 1027

through public guardians or the criminal justice system. The courts may defer sentencing of convicted patients who participate in treat- ment or may require that patients receive treatment as a condition of discharge after involuntary commit- ment. Coercive treatment has been associated with improved treatment retention in difficult dually diag- nosed patients (17,19).

Persuasion Persuasion is the process of convinc- ing engaged patients to accept long- term abstinence-oriented treatment (23,28,29). Accomplishing this phase of treatment is difficult for several reasons. First, patients who are unemployed or disaffiliated may escape social pressures that often in- duce other substance abusers to seek treatment. Second, dually diagnosed patients, and sometimes their thera- pists, may excuse their substance use as secondary to their psychiatric dis- orders. Finally and perhaps most im- portant, patients’ impaired ability to process information due to thought disorder, depressive cognition, or organic brain syndromes com- promises their ability to transcend denial (23), a core part of all sub- stance abuse syndromes (28,30).

While clinicians often view pa- tients’ motivation as a trait rather than a state, a variety of interven- tions may improve treatment accep- tance and retention. These modal- ities range from focused psychother- apies (17,31) to prerehabilitative groups (23,29,32). The basic prin- ciples ofpersuasion apply to all these activities (28). Clinicians should be clear and consistent in presenting diagnoses and their treatment im- plications. Discussion of objective data, such Breathalyzer or urine test results, abnormal laboratory or phy- sical findings, psychiatric symptoms, and social or legal difficulties related to substance abuse, can help per- suade patients to accept treatment.

Hospitalization presents an excel- lent opportunity to persuade dually diagnosed patients that they need

substance abuse treatment. In- patients have in some way acknowl- edged their distress, are more likely to be abstinent, are already in the patient role, and have credible peers

available on the ward. Their psychi- attic disorder may be relatively stabi- lized. In these circumstances, group therapy focused on persuasion has shown moderate effectiveness in moving patients toward acceptance ofsubstance abuse intervention (23).

During the persuasion phase, cli- nicians should focus their attention on the overall readiness of patients to commit themselves to treatment. A patient’s premature commitment to behavioral change involving sub-

stance use may lead to a sense of frustration or failure. For patients who acknowledge the need for treat-

ment, assurances ofongoing support

despite early lapses must be explicit.

Active treatment Active, or primary, treatment is fo- cused on helping patients develop the attitudes and skills necessary to remain sober. A range of behavioral, psychoeducational, and medical in- terventions may be offered, al- though no studies have yet com- pared specific program components. The type and timing of interventions can be determined only by clinical assessment ofindividual patients’ ill- nesses and needs.

Prolonged abstinence is difficult for the dually diagnosed patient. Un- fortunately, some treatment pro- grams lower their expectations of dually diagnosed patients, accept

reduced substance use as a goal, or tolerate frequent relapse as inevi- table. However, dually diagnosed patients are likely to suffer worse consequences with relapse than primary substance abusers. Some data suggest that negative conse- quences for the dually diagnosed patient can occur at relatively low levels of alcohol or illicit drug use (3). In addition, treatment programs that accept goals other than abstinence may contribute to pa- tients’ exclusion from self-help groups such as Alcoholics Anony- mous (AA), which may be a valuable resource for helping dually diag- nosed patients maintain sobriety (17,2 1).

It is important for programs to es- tablish a culture of abstinence as an integral part of their therapeutic milieu. Contracts with contingencies that stipulate the consequences of

lapses may help formalize patients’ commitment to change. In the authors’ experience, such contracts have been useful in the early phases oftreatment. Despite temporary set- backs, high expectations for patients’ ability to end their addiction should be maintained if patients are to re- main hopeful.

Relapse prevention Abstinence is not the end of sub- stance abuse treatment for the dually diagnosed patient. Most of the van- ance in long-term outcomes of pri- mary substance abuse treatment can be accounted for by events that transpire after active treatment and the initial cessation of substance abuse (33). Maintenance requires an ongoing connection between the patient and trusted health care providers. During this phase of treat- ment, the clinician should point out the patient’s successes but should also monitor the patient for pro- dromes to relapse.

Lapses or “slips” following absti- nence are to be anticipated. The pa- tient’s cognitive and affective re- sponses to these lapses may deter- mine the degree to which the patient will return to his former behavior (34). Both the clinician’s and the patient’s anticipated responses to lapses should be discussed before they occur. Relapse can be a learning experience. The discovery and rapid arrest ofiitial lapses may help in the prevention oflater ones.

Progression through these phases

may take a considerable amount of time for individual patients. Patients may regress to earlierphases because of changes in addictive behavior or ambivalent commitment to treat- ment goals. Clinicians need peer support and insightful supervision to maintain a positive attitude toward the dually diagnosed patient. At- tending Al-Anon meetings may help the clinician maintain a balanced re- lationship with the patient.

Treatment components The integration of substance abuse treatment into mental health settings involves a broad range of specialized services. The following sections de- scribe core components required throughout the treatment process.

1028 October 1989 Vol. 40 No. 10 Hospital and Community Psychiatry

The relative necessity of these com-

ponents is determined by the pa- tient’s clinical condition.

Program milieu. The program

environment will affect retention of patients over time ( 1 0). For the more disturbed chronic psychiatric pa- tient, highly structured but low-in- tensity programs are necessary (35). Impulsecontroishould be promoted in the hope that social norms will be internalized, allowing patients to ad- just more adequately to the com- munity. The literature on expressed

emotion (36)suggests that treatment settings should seek to reduce inter-

personal stimulation. Some authors advocate psychoeducational pro- gramming (21,37). Available pro- gram descriptions are consistent with these principles for structuring the treatment milieu (17,20,21).

Case management. In the treat- ment of the dually diagnosed pa- tient, a primary ongoing therapeutic relationship is necessary. For the

severely disturbed patient, this rela- tionship may be with a case manager. Assertive case management models, which were developed to respond to the needs of difficult-to-treat psychi- attic patients (38), have been recom- mended for the dually diagnosed patient (39).

In these models, case managers perform assertive outreach, link pa- tients with direct services, monitor patients’ progress through a variety of milieus, educate patients about psychiatric and substance abuse dis- orders, reiterate treatment recom- mendations, and coordinate treat- ment planning across programs. In developing individualized treatment plans, the case manager clarifies the patient’s expectations and explains what the patient can expect from the case manager. Research is under way

to determine if assertive case man-

agement is effective for the dually diagnosed population (39).

Group therapy. Alongwith other clinicians (17,20,21), we consider group therapy the foundation of ac- tive treatment interventions for the dually diagnosed patient. Even severely disturbed patients can

benefit from group therapy (40). Group participants should be

screened for verbal, social, and cog- nitive skill levels. These assessments

can be used to create groups com- posed ofpatients with similar levels

of functioning.

In groups for lower-functioning patients, the pace should be slow. Less confrontation and more active group leaders are appropriate. Solic- itation of thoughts and feelings may be minimal; instead the group may focus on symptom reduction and be-

havioral change. In higher function- inggroups or over a longer period of time in lower-functioning groups, more peer interaction is promoted. The development and monitoring of individual treatment contracts by the

group is encouraged.

A psychoeducational approach

has been proposed for the treatment of dually diagnosed patients within groups (2 1 ,4 1). Providing informa- iion while developing a supportive peer group facilitates movement through treatment phases. Under- standing and acceptance of both the psychiatric illness and the substance dependence, obtaining an awareness ofthe patients’ prodromes and active symptoms, and promoting medica- tion compliance are ongoing tasks in group therapy of dually diagnosed patients.

Psychopharmacology. Dually di- agnosed patients with poorly con- trolled psychiatric symptoms or dis- tressing drug side effects such as akathisia are more likely to resume substance abuse. A dually diagnosed patient’s psychiatric disorder will often respond to medication, al- though increased attention to the patient’s medication compliance is necessary. The use of long-acting depot neuroleptics may be helpful. However, the use of minor tran- quilizers with addiction-prone pa- tients is controversial (42). Clini-

cians should be aware ofthe possible abuse ofanticholinergic agents, such as benztropine and trihexyphenidyl (43), and should carefully review their use.

The interaction between pre- scribed drugs and abused psychoac- tive substances is another area that requires monitoring. Clinicians must consider metabolic interactions,

such as enzyme induction, and phys- iologic interactions, such as neuro- transmitter dysregulation, when pre- scribing medication to addicted pa-

tients. These poorly understood interactions are less problematic as patients reduce and eliminate their substance abuse.

The use of disulfiram in patients with psychotic disorders is parti- cularly controversial. Despite �he reported psychotogenic effects me- diated by dopamine beta-hydroxy- lase (44,45), our experience suggests that disulfiram is less of a risk to pa- tients’ psychiatric status than alcohol if they are psychiatrically stabilized and placed on appropriate main- tenance pharmacotherapy before

disulfiram is administered. Dually diagnosed patients have been found to be at least as compliant with disul- firam as primary alcoholics (17,46). Valid consent (47) is necessary be- fore prescription of any medication, particularly disulfiram.

For opiate-dependent dually di- agnosed individuals, methadone maintenance treatment may be use- ful. Methadone will not interfere with the action ofantipsychotics and may even enhance their effective- ness (48). The role of the narcotic antagonist naltrexone with dually diagnosed patients has not been ade- quately studied. Desipramine has been reported to reduce craving and relapse in cocaine-dependent pa- tients (49) and could also have a role in the management of coexisting af- fective disturbances.

Detoxification. Detoxification may be a necessary, but never suffi- cient, component in the treatment of substance dependence. While am- bulatory detoxification is possible, many dually diagnosed patients may require hospitalization for behavior-

al control or medical management. Such patients have historically been poorly tolerated in nonhospital com- munity detoxification centers and frequently must be treated on psy- chiatric wads (22).

Because intoxicated patients are especially impulsive, evaluation of personal and community safety is paramount. The site for detoxifica- tion of the dually diagnosed patient

Hospital and Community Psychiatry October 1989 Vol. 40 No. 10 1029

will be determined partly by an as-

sessment of the potential for be- havioral disturbance and of staff capacities for managing disturbance. When hospitalization is deemed necessary, the patient should be in- formed of all factors contributing to that recommendation. The patient should also be told that detoxifica-

tion without rehabilitation is of no long-term benefit. The expectation that the patient will use the hospital stay to initiate rehabilitative treat- ment should be made clear.

Whether patients with preexist- ing psychotic disorders are more

prone than primary substance abusers to severe withdrawal psy- choses is unclear. The differential diagnosis of psychotic symptoms in

the setting of acute withdrawal is both difficult and essential. Objec- tive data such as vital signs, evidence of tremor and hyperreflexia, pupil size, and the results of Breathalyzer tests and urine or serum drug screens are necessary for differential diag- nosis and treatment. The psychotic

symptoms of acute withdrawal may require management with antipsy- chotic agents, but these symptoms usually remit within two weeks (50). The need for maintenance antipsy- chotics should be reassessed after withdrawal features have cleared.

Toxicologic screening. Regard- less of a substance abusers’ underly- ing psychiatric status, denial and deceptive behaviors are part of the disease process even in the most im- paired patients. The role ofthese be- haviors has been highlighted by Al- terman and associates’ finding (51) that more than half of alcoholic schizophrenic patients continued to drink while hospitalized and by Hel- zer and Pryzbeck’s report (25) that although dually disordered alcoholic

patients are morelikely to seek treat- ment than primary alcoholics, they are no more likely to have discussed their drinking with a treating phy- sician.

Programs for dually diagnosed patients should use random Breath- alyzer and urine drug screens to detect unacknowledged relapse. The belief that patients’ capacity for deception is diminished by psychiat-

ric illness is frequently challenged by the positive results ofroutine chemi- cal testing. Such testing reinforces the abstinence orientation of the treatment milieu, provides patients with an external reason to remain abstinent during the period before their internalization of this goal, and offers patients who are successfully abstinent an opportunity to ex- perience growing credibility and

self-confidence within the treatment

program. Family involvement. F a m i 1 y

members are often the first to recog-

nize the destructive consequences of substance abuse in their loved ones’ psychiatric course. They should be informed ofthe vulnerability of their family member’s illness to what may appear to be harmless drug use. They will need help in finding a deli- cate balance between offering sup-

port to their family member and ac- ting in ways that enable him to con-

tinue destructive drug use.

Family involvement in develop-

ing treatment contracts and monitor- ing compliance can increase patient

motivation. Including family psy- cheducation (52) in the treatment program may reduce not only episodes ofpatient relapse but also

the family’s perceived burden (37). The National Alliance for the Men- tally Ill (NAMI), a family support network, has been active in seeking

services for dually diagnosed pa- tients. Al-Anon may help families

understand and respond to alcohol abuse problems. These support

groups can help families maintain a caring relationship with their dually diagnosed member through all phases of treatment.

Self-help groups. The use of self- help groups in the treatment of the dually diagnosed patient must be

evaluated on a case-by-case basis. Frequent, accessible, and inexpen- sive meetings, a positively focused and structured 1 2-step recovery pro- gram, and the possibility of meaning- ful personal sponsorship make this kind of intervention an important component of many treatment plans for dually diagnosed patients. How- ever, a patient’s ability to internalize the programs of Alcoholics Anony-

mous or Narcotics Anonymous ap- propriately or to fit into a specific meeting should not be assumed.

While AA principles are not anti-

psychiatry or antimedication, those sentiments may exist within in- dividual members or groups and should be discussed before the patient attends AA events. Case managers may attend meetings with their clients and process the informa- tion with them afterward. Some dually diagnosed patients may at

times be too disruptive for these meetings and should be discouraged from attending until they have be- come more stable.

The emergence of self-help groups with specific dual-diagnosis orientations has been a welcome al- ternative for more severely impaired patients. While using AA principles, the dually diagnosed members em- pathically support mental health treatment and tend to be more tolerant of deviant behaviors. Many of the successfully recovering dually diagnosed patients treated by the authors have used self-help groups as part oftheir treatment.

Conclusions Severe psychiatric disorders impair the ffectiveness of traditional sub- stance abuse treatments. Nonethe- less, treatment interventions for dually diagnosed patients ranging

from modest modifications (2 1) to complex new programs (1 7,20) may reduce this effect and produce improvement in some previously refractory patients. The integration of substance abuse treatment into mental health settings augments the community support programming that currently exists for the severely and chronically mentally ill. Cli- nicians must define, develop, imple- ment, and scientifically evaluate programs for the dually diagnosed patient.

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