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JOURNAL OF DUAL DIAGNOSIS, 7(3), 175–185, 2011 Copyright C© Taylor & Francis Group, LLC ISSN: 1550-4263 print / 1550-4271 online DOI: 10.1080/15504263.2011.593418

CLINICAL FORUM

Treatment of a Young Man With Psychosis and Polysubstance Abuse

Mary R. Woods, RN, LADAC,1 and Robert E. Drake, MD, PhD2,3

This clinical forum presents the potential of implementing evidence-based dual diagnosis services in the private sector. Family members started and continue to oversee the WestBridge program based on a steadfast commitment to evidence-based care.

An initial case presentation describes a young man who had repeatedly floundered in separate mental health and addiction treatment programs but was able to recover within an evidence-based approach. The case represents an amalgam of several typical program participants.

The authors describe several refinements of evidence-based practices developed within the program. These include a philosophy of dual recovery; a personalized integration of mental health, substance abuse, and physical health interventions; safe, flexible, and recovery-oriented housing; a multidisciplinary, community-based team; extensive use of mentors, peer support, and 12-step meetings; family education and support; supported education and employment; team- based medical and medication management; and holistic treatment.

The WestBridge model incorporates many elements of health care reform: a medical home, in- tegrated interventions, bundled payments for value rather than for amount of services, participant- centered care, commitment to information technology, and a reduction of middle managers. Early, intensive, evidence-based care is expensive but may lead to prolonged recovery and substantial cost savings over time. As such, this approach to dual diagnosis services may be a model for health care reform.

CASE PRESENTATION

Jon was a 25-year-old man with a history of psychosis, hypomania, alcohol abuse, marijuana abuse, and LSD abuse when his family contacted WestBridge. He was under observation at

1WestBridge Community Services, Manchester, New Hampshire, USA 2Department of Psychiatry, Dartmouth Medical School, Lebanon, New Hampshire, USA 3Dartmouth Psychiatric Research Center, Dartmouth Medical School, Lebanon, New Hampshire, USA

Address correspondence to Mary R. Woods, WestBridge Community Services, 1361 Elm St., Suite 207, Manchester, NH 03101, USA. E-mail: [email protected]

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his hometown community hospital in a Midwestern state after wandering into a local mall and shouting obscenities. Since the age of 18, he had a history of eight admissions to inpatient mental health facilities and four admissions to inpatient addiction programs. Testing at the time of his current admission revealed the presence of amphetamines and marijuana, a blood alcohol level of 0.08, and a lithium level of 0.4. He reported taking risperidone sporadically.

Jon’s family history included several male relatives with alcoholism and depression on both sides of the family. His parents were both professionals. The family had a long-term housekeeper, but both parents had been involved in their children’s activities.

During high school, Jon was an above-average student who excelled in math and music. He received a university scholarship, was majoring in accounting, and played in the school band. His freshman year was stressful and complicated by partying, binge drinking, and using marijuana and LSD. During his first summer break, he began to hear voices coming from the television when it was turned off. Concerned with Jon’s behavior, his family brought him to a local psychiatrist, who admitted Jon to an inpatient psychiatric hospital for evaluation. Friends brought Jon marijuana and LSD, which he used throughout his admission. His substance use was never assessed.

Over the course of the next 2 years, Jon continued to use alcohol and other drugs, experiencing periods of brief psychosis, and flunked out of college. He returned home and worked in his father’s business, but increasing delusions and paranoia led to several admissions to various treatment facilities.

When the family contacted WestBridge, they were feeling hopeless, stressed, and fearful. Jon’s siblings were angry about his behavior, feeling that their parents were spending too much time, effort, and money on their brother. Jon had assaulted each of them, had been drunk and delusional at his sister’s wedding, and had disrupted many family gatherings. Family therapy had not helped. Jon was troubled by his lack of academic progress and his paranoia, and he felt regret and shame over his relationships with family members. Nevertheless, he believed that his use of alcohol and other drugs was not a problem.

The admission team explained WestBridge’s services, including the use of several evidence- based treatment interventions, by telephone. Two staff members then flew to the Midwest to meet with Jon and his family. Over the course of 2 days, they explained the program, assessed Jon, and answered questions.

Almost immediately, Jon’s father brought him to New Hampshire for admission to West- Bridge’s residential program. The team reviewed Jon’s individual and family needs and helped them to develop a Personal Achievement Plan that articulated their short-term and long-term goals. Jon’s agenda included developing skills to identify and cope with delusions and paranoia, improving his relationships with all his family members, attending college, and finding a job.

Jon entered the Commons, a residential treatment agency for adult men (aged 18 or older) experiencing co-occurring severe mental illness and substance use disorders. During his first 2 weeks, he received a full medical and psychosocial assessment, achieved a therapeutic level of lithium and risperidone, and attended groups on drug education, coping with stress, anger management, relapse triggers, psychoeducation, men’s issues, illness management, and 12-step support. He developed a Wellness Recovery Action Plan, which he shared with his family. He participated in cognitive behavioral therapy to learn to manage symptoms of mental illness; motivational interviewing to resolve his ambivalence about drugs; daily exercise, art group, and yoga with other residents; and weekend activities in the community. Although unwilling to attend community self-help groups initially, he participated in recovery groups in the Commons. The

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program internist diagnosed sleep apnea and referred Jon to a sleep clinic, where he received a continuous positive airway pressure (CPAP) device and a sleep hygiene plan.

During 4 months at the Commons, Jon completed the illness management and recovery program and began to use new coping skills. He and his family participated in family education and support, in which they developed an agreement that allowed everyone to feel safe and begin recovering. Each family member committed to a goal: Jon’s mother to going to the gym three times a week, his father to practicing the piano three times a week, his sister to taking a college course, and his brother to joining a basketball team. They learned to communicate effectively, to solve problems as a family, to cope with stress, and to manage addiction and mental illness. Jon’s mother and father started to sleep well at night and were more available to the other children.

Meanwhile, Jon transitioned into the community gradually over 2 weeks, spending every other night in his apartment with the support of mentors and sleep coaches. The Assertive Community Treatment team followed him closely and helped him to attend therapeutic activities that he chose: illness management and recovery group, men’s group, cooking skills group, coffee group (a social group), and individual dual diagnosis counseling.

Evening mentors (described below) helped Jon with his college classes, activities of daily living, exercise, and attending one self-help meeting each week. Sleep coaches helped him to develop new sleep habits and to use his CPAP machine. Jon volunteered at a local camp doing landscaping and painting while attending college. He began to identify with mentors and to enjoy the young people’s self-help meeting, concluding that he needed to abstain from alcohol, marijuana, LSD, and other drugs if he was going to finish school and have a career.

One year after entering WestBridge, Jon had completed two college courses, was enrolled in additional courses, was attending self-help meetings three nights a week, had a sponsor, was work- ing as a cashier 20 hours a week, and was managing his mental illness, addiction, and sleep apnea.

DISCUSSION

As this clinical narrative illustrates, people with dual diagnosis can do well when they receive effective treatments and supports. Financial resources, personal strengths, and familial supports help, but evidence-based services are essential. Many people with co-occurring disorders who have fared poorly in non-integrated or non–evidence-based programs are able to recover—to manage their illnesses, to maintain abstinence, to pursue educational and occupational goals, and to develop positive relationships with families and peers—when they receive integrated, evidence-based services.

In the following discussion, we first describe several elements of evidence-based care at WestBridge and then consider the potential of this model for health care reform.

Evidence-Based Practices

Interventions that are proven to be effective by rigorous research studies are called evidence-based practices (Institute of Medicine, 2001; New Freedom Commission on Mental Health, 2003). Several effective interventions for people with serious mental illness and co-occurring substance use disorder exist (Drake, O’Neal, & Wallach, 2008), but current programs rarely provide these

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services (Epstein, Barker, Vorburger, & Murtha, 2004). Even programs that identify themselves as dual diagnosis programs usually fail to provide the most effective services (Drake & Bond, 2010).

What are evidence-based practices for people with co-occurring disorders? Integrated mental health and addiction interventions, safe housing, Assertive Community Treatment, residential treatment, dual diagnosis groups led by professionals, supported employment, medications for mental disorders and for addictions, and contingency management are all supported by controlled research studies (Brunette, Mueser, & Drake, 2004; Drake et al., 2008; Mueser, Campbell, & Drake, 2011; Tsemberis, Gulcur, & Nakae, 2004). Peer support groups are supported by many correlational studies (Monica, Nikkel, & Drake, 2010). Other interventions, such as motivational interviewing, cognitive behavioral treatment, family interventions, strengths-based care man- agement, sleep therapies, supported education, and trauma treatments, are not yet supported by rigorous research but are promising components of a comprehensive dual diagnosis program. The clinical details of these interventions are described in detail in several textbooks and manu- als (Brunette, Drake, Lynde, & the Integrated Dual Disorders Treatment Group, 2002; Mueser, Noordsy, Drake, & Fox, 2003; Corrigan, Mueser, Bond, Drake, & Solomon, 2008; Swanson & Becker, 2011; Fox et al., 2010).

One compelling feature of the WestBridge program is that clinicians, clients, families, and researchers have collaborated for 10 years to refine several of these evidence-based practices. We next describe these refinements and how they are combined and individualized.

Philosophy

WestBridge combines evidence-based practices with an overall philosophy of dual recovery, optimism, strengths, shared decision making, and harm reduction, consistent with concepts in the literature for many years but rarely realized in actual practice (Minkoff, 1989; Ridgely, Goldman, & Willenbring, 1990; Carey, 1996; Mueser et al., 2003; Fox et al., 2010). Clients and families are encouraged to develop realistic recovery goals that address illness self-management, safe housing, respectful interactions with family members, peer friendships that do not involve substances of abuse, physical wellness, and mainstream education and employment. Participants identify their own specific goals, actively choose interventions, and develop their own recovery plans within a process of shared decision making that involves transparency, access to the most recent scientific information, and personal preferences (Mueser & Drake, in press).

The program’s optimistic philosophy regarding dual recovery is bolstered by evidence that most people do recover from dual disorders (Drake, Xie, McHugo, & Shumway, 2004; Drake et al., 2006). Recovery occurs in several domains, in different sequences, at different times, and following various pathways (Xie, McHugo, Sengupta, & Drake, 2003; Xie, Drake, & McHugo, 2006; Xie, Drake, McHugo, Xie, & Mohandas, 2010). Early intervention and evidence-based practices facilitate recovery by helping people to recover at a faster pace and preventing the most serious adverse consequences of illness (McGorry, Killackey, & Yung, 2010).

Integration

Service integration entails combining and individualizing interventions for mental health, addiction, physical health, and psychosocial functioning for people who have dual disorders. The

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client and family participate in identifying goals and preferred interventions, but the clinical team takes responsibility for integrating these interventions into a coherent package. Integration affects all aspects of care. For example, medication management addresses not just symptom control but also interactions with abused drugs, side effects, and physical health. Family education and support encompass mental illness, addiction, co-occurring disorders, physical wellness, and psychosocial issues. Supported education and employment help people to find school programs and jobs of their choice in regular community environments that are supportive and free of addictive behavior. Social skills training targets making friends who are abstinent, avoiding drug purveyors, and maintaining a healthy lifestyle.

The evidence for mental health and addiction service integration is robust (see Drake, Mueser, Brunette, & McHugo, 2004; Drake et al., 2008; Dixon et al., 2010 for reviews). People with multiple needs have difficulty participating in fragmented, non-integrated services; attending many programs and making sense of divergent messages from various sources confuse people and lead to poor access or disengagement. Combining services in one multidisciplinary team is more efficient, practical, and effective. Research consistently shows that integrated services are more effective than non-integrated services.

Housing

Within the overall philosophy of dual recovery, safe, flexible, recovery-oriented housing is a cornerstone (Alverson, Alverson, & Drake, 2000). The WestBridge approach to housing is unique but consistent with the evidence. Participants who need stabilization begin their expe- rience at the Commons, a residence for 10 to 12 men where they learn about dual diagnosis, stop using substances, achieve symptom control with a minimal medication regimen, become acculturated to 12-step philosophy, and bond with other participants, mentors, and staff members. Need rather than insurance coverage determines length of stay at the Commons, but clients are encouraged to transition rapidly to independent living, usually within 2 or 3 months, with as much support as needed. Relapses or other difficulties can occasion a return to the Commons for whatever time is needed to get back on a recovery track. Movement toward independent living is rapid, individualized, strongly supported by staff, and flexible in pace. Participants do not remain in or move to supervised group homes; instead, Assertive Community Treatment teams provide outreach and support to independent living settings. Participants are not dismissed from housing or the program because of a relapse. Some do leave the area to return to college or to their hometowns, but most stay nearby in independent housing to complete college or pursue careers.

The evidence for safe housing and flexible transitions to the community is extensive, although the specific types of housing arrangements vary extensively (Tsemberis et al., 2004; Brunette et al., 2004; McHugo et al., 2004). One consistent finding is that transitions from residential treatment to the community should be gradual and flexible, allowing for movement back and forth with supports as needed. In most studies successful residential treatment lasts for at least 9 months (Brunette et al., 2004). The WestBridge experience shows, however, that residential treatment can be much briefer if transitions to independent living are flexible and supports are generous.

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Assertive Community Treatment

A multidisciplinary team engages clients in the community using outreach, support, moti- vational interviewing, and other techniques. The team provides treatment and support in the community 24 hours per day, 7 days a week. The team includes care managers, a vocational spe- cialist, a nurse, an addiction counselor, a part-time psychiatrist and internist, and a team leader. Mentors (described below) are also part of the team. Daily meetings and frequent electronic com- munications allow the team to individualize and coordinate services. Motivational interviewing helps clients to work through ambivalence around sobriety, taking medications, and pursuing meaningful goals.

Assertive Community Treatment enables people with multiple difficulties to maintain stable housing and to avoid hospitals and homeless settings (Mueser, Bond, Drake, & Resnick, 1998). The multidisciplinary team incorporates dual diagnosis treatments, supported employment, and other evidence-based interventions.

Peer Support, 12-Step Meetings, and Mentors

Young people are of course intensely interested in relationships with peers, and these influences can impede or facilitate recovery. At the Commons, the young men participate together in several discussion groups each day, attend Alcoholics Anonymous (AA) and other 12-step meetings together, go to the gym and to other activities together, and make plans for school, work, and independent housing together. The net result is that they support each other’s recoveries.

AA and other 12-step groups can provide peer support, education, optimism, mentors, spiritu- ality, coping strategies, and other supports for recovery. Participants at WestBridge are introduced to the 12-step philosophy through discussion groups, interactions with staff, and attending meet- ings in the community. In addition, mentors, who may be AA members with long-term sobriety or people who have been educated and oriented to self-help programs, are employed to help participants with evening activities, including but not limited to attending 12-step groups. The mentoring program enables a large proportion of participants to find role models and to connect with the AA fellowship. For many participants, friendly support for AA attendance and oppor- tunities to discuss the principles and steps of AA with a mentor may be necessary to facilitate connections with 12-step groups.

The evidence for 12-step involvement among people with co-occurring disorders is mixed. Some studies have found limited involvement (Noordsy, Schwab, Fox, & Drake, 1996), but several others have found that involvement nevertheless correlates with recovery (Monica et al., 2010). The critical difference may be explained by some combination of introduction procedures, support for attendance, and the availability of programs that are modified for people with co-occurring disorders, such as Dual Diagnosis Anonymous.

In addition, professionally led peer groups are effective in controlled trials of dual diagnosis treatments (Drake et al., 2008). The finding that different types of groups are effective across these trials suggests that common elements, such as peer support, are more important than any particular model of intervention.

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Family Education and Support

Many WestBridge participants have had difficult and even fractured family relationships before entering the program. Learning to communicate clearly without acrimony and develop- ing positive family supports are therefore important aspects of recovery for many people. All families participate in weekly family education and support meetings, usually via conference calls. Family members and participants frequently report an increase in support, understanding, and optimism.

Evidence for the effectiveness of family education and support is abundant in both the addiction and serious mental illness fields but is just emerging in the dual diagnosis field. Longitudinal evidence confirms the importance of family support for dual diagnosis clients (Clark, 2001). One randomized controlled trial included family psychoeducation in a successful intervention package (Barrowclough et al., 2001).

Supported Education and Employment

Recovery involves pursuing activities that provide structure, social contacts, and meaning- ful roles. For most adults in the United States, meaningful roles in society include education and competitive employment. Supported education and employment are therefore essential for people with dual diagnosis. All participants at WestBridge plan for functional recovery from the beginning of treatment, and the great majority are working and/or going to school within 6 months.

Supported employment consistently helps approximately two-thirds of people with dual di- agnosis to obtain competitive employment (Sengupta, Drake, & McHugo, 1998; Mueser et al., 2011). Although dual diagnosis clients are often screened out of vocational services (Frounfelker, Wilkniss, Bond, Devitt, & Drake, 2011), they do as well as single diagnosis clients when they access services. Younger clients are of course interested in education as well as employment; supported education and supported employment services can be combined effectively by the same specialists (Nuechterlein et al., 2008; Rinaldi et al., 2010). Abstinence is not a prerequi- site for supported employment; the evidence shows instead that employment typically precedes abstinence and probably motivates clients to stop using alcohol and drugs (Xie et al., 2010).

Medication and Medical Management

WestBridge provides a nurse, a psychiatrist, and an internist to integrate psychiatric and medical care with rehabilitation and recovery. A full-time nurse on the team optimizes the role of doctors and facilitates daily check-ins regarding medications and side effects. Because perverse insurance regulations and payments are not involved, the nurse can be constantly available by e-mail and telephone. Daily monitoring and intensive supports allow the team to avoid polypharmacy, to use clozapine optimally, to offer medications for addiction to those who are interested, and to avoid addictive medications and dangerous interactions.

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Evidence for the effectiveness of psychotropic medications is of course extensive. At the same time, research shows that many people with complex disorders are vulnerable to over- medication, polypharmacy, and cumulative side effects (NASMHPD Medical Directors, 2001). People with psychosis, especially those with co-occurring substance use disorders, are unlikely to receive appropriate clozapine trials and addiction medications and are likely to be overpre- scribed opiates, benzodiazepines, and sleep medications (Brunette, Noordsy, Xie, & Drake, 2003). Systematic medication management following evidence-based algorithms and standardized as- sessments avoids all of these errors (Miller et al., 2004).

Holistic Treatment

Dual diagnosis is often a misnomer because most people with serious mental illness and substance use disorder have multiple challenges. In addition to dual diagnoses, they may, for example, have trauma histories, learning disabilities, legal entanglements, pain syndromes, sleep disorders, and other issues that impede recovery and require attention. Effective treatment com- bines interventions for all relevant conditions into a coherent package of holistic treatment.

The evidence for holistic treatment of this type is minimal because such services are rarely provided, are idiosyncratically complex, and have not been studied. Perhaps the best evidence for integrating multiple interventions is the extensive research on Assertive Community Treatment (Mueser et al., 1998).

Health Care Reform

Some might argue that private dual diagnosis treatment, other than refining specific components of care, has minimal relevance for the public sector and for health care reform. An opposing view asserts that private treatment may offer models for health care reform. The WestBridge approach, for example, incorporates many elements of proposed health care reforms (Agency for Healthcare Research and Quality, 2011; Bielaska-DuVernay, 2011; Cutler, 2004; Fowler, Levin, & Sepucha, 2011; Gao et al., 2011; Institute of Medicine, 2001; New Freedom Commission on Mental Health, 2003; U.S. Department of Health and Human Services, 2011). Families pay for value, represented by recovery, rather than for amounts of services. Multidisciplinary teams offer a medical home by coordinating and integrating physical and behavioral health care. Interventions are completely client-centered; clients and families negotiate their goals up front using shared decision making, and the model emphasizes self-management from the beginning. WestBridge is developing information systems to insure that research findings, treatment plans, and outcomes are transparent. Independence and use of community resources, rather than dependence on the mental health system, are primary goals. Insurance companies, regulators, and other middle managers are largely eliminated from the picture.

Is the cost of private dual diagnosis care really prohibitive? Research increasingly demonstrates that early and intensive use of effective interventions may actually save health care costs over the long run (see, e.g., Jacobson, Mulick, & Green, 1998; Gatchel et al., 2003; Banerjee & Wittenberg, 2009). For people with complex co-occurring disorders, evidence-based treatment

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may prevent years of disability, high health care utilization, incarceration, community costs, and human costs. Economic modeling may show that over the long run, costs for evidence-based care are lower than for ineffective care. The hypothesis merits careful study.

DISCLOSURES

Ms. Woods and Dr. Drake report no financial relationships with commercial interests with regard to this manuscript. Dr. Drake serves as a consultant to WestBridge Community Services.

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2011, Volume 7, Number 3

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