Integrated Treatment for
Dual Disorders
Kim Mueser, Ph.D.
Dartmouth Medical School
NH-Dartmouth Psychiatric Research Center
Kim.t.mueser@dartmouth.edu
Overview
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Epidemiology
Why focus on dual disorders?
Models of etiology
Assessment
Treatment principles
Research
Avoiding the blame/demoralization trap
Any Substance Use Disorder
Prevalence % of Substance Use
Disorder
60
50
40
30
20
10
0
Gen.Pop
Schiz
BPD
MD
OCD
Phobia
PD
Rates of Lifetime Substance Use Disorder (SUD) among
Recently Admitted Psychiatric Inpatients (N=325) (Mueser et
al., 2000)
% of Clients with SUD
100
75
50
25
0
Schizophrenia
Schizoaffective Disorder
Bipolar Disorder
Major Depression
Factors Influencing Prevalence
of Substance Use Disorders
(SUD):
Client Characteristics
Higher Rates
• Males
• Younger
• Lower education
• Single or never married
• Good premorbid
functioning
• History of childhood
conduct disorder
• Antisocial personality
disorder
• Higher affective
symptoms
• Family history SUD
Factors Influencing Prevalence
of Substance Use Disorders:
Sampling Location
Higher Rates
• Emergency rooms
• Acute psychiatric
hospitals
• Jails
• Homeless
• Urban setting
(drugs)
• Rural setting
(alcohol)
Major Subgroups of
Comorbid Clients
• Severely mentally ill - psychotic
Frequently abuse moderate amounts of
substances
 Small amounts of substance use trigger negative
consequences

• Anxiety and/or depression

Substance use can cause or worsen symptoms
 Frequently
abuse moderate to high
amounts of substances
• Personality Disorders
 Antisocial
& borderline most common
 Frequently abuse high amounts of
substances
Clinical Epidemiology
1. Rates higher for people in treatment
2. Approximately 50% lifetime, 25%
35% current substance abuse
3. Rates are higher in acute care,
institutional, shelter, and emergency
settings
4. Substance abuse is often missed in
mental health settings
Why Focus on Dual
Disorders?
1. Substance abuse is the most common cooccurring disorder in persons with severe
mental disorders
2. Significant negative outcomes related to
substance abuse:
1) Clinical relapse & rehospitalization
2) Demoralization
3) Family stress
4) Violent behavior
1) Incarceration
2) Homelessness
3) Suicide
4) Medical illness
5) Infections diseases
6) Early mortality
3. Outcomes improve when
substance abuse remits
4. Poor treatment is expensive for
families and society
Reasons for High Comorbidity
Rates of Severe Mental Illness and
Substance Abuse
• Berkson’s Fallacy
• Self-medication*
• Super-sensitivity to effects of
substances*
• Socialization motives
• Precipitation of psychosis from
substance use
• Common factors
 Poverty/deprivation
 Neurocognitive
impairment
 Conduct disorder/antisocial personality
disorder
Self-Medication:
 More symptomatic clients don’t abuse more
substances
 Substance selection unrelated to type of
symptoms experienced
 Types of substances abused unrelated to
psychiatric diagnosis
 Self-medication may contribute to some
comorbidity but doesn’t explain all
 More evidence supporting self-medication in
anxiety disorders (PTSD)
Super-sensitivity Model:
 Biological sensitivity increases vulnerability to
effects of substances
 Smaller amounts of substances result in
problems
 “Normal” substance use is problematic for
clients with severe mental illness but not in
general population
 Sensitivity to substances, rather than high
amounts of use, makes many clients with
mental illness different from general
population
Stress-Vulnerability Model
Medication
Substance
Abuse
Biological
Vulnerability
Severity
of SMI
Stress
Coping
Status of Moderate Drinkers with
Schizophrenia 4 - 7 Years Later (N=45)
100%
80%
60%
55.6
40%
20.0
20%
24.4
0%
Abstinent
Moderate
Drinker
Source: Drake & Wallach (1993)
Alcohol
Use
Disorder
Support for Super-sensitivity Model:
Dual disorder clients less likely to develop physical
dependence on substances
 Standard measures of substance abuse are less
sensitive in clients with severe mental illness
 Clients are more sensitive to effects of small
amounts of substances
 Few clients are able to sustain “moderate” use
without impairment
 Super-sensitivity accounts for some increased
comorbidity

Overview of Assessment of
Substance Abuse in Clients
with Severe Mental Illness
Detection
Classification
Functional
Assessment
Functional
Analysis
Treatment
Planning
• Psychological Dependence - Use of more
substance than intended, unsuccessful attempts to
cut down, giving up important activities to use
substances, or spending lots of time obtaining
substances.
• Physical Dependence - Development of tolerance to
effects of substance, withdrawal symptoms following
cessation of substance use, use of substance to
decrease withdrawal symptoms.
Functional Assessment
• Goals: To understand client’s functioning across
different domains and to gather information about
substance use behavior
• Domains of Functioning
1. Psychiatric disorder
2. Physical health
3. Psychosocial adjustment (family & social
relationships, leisure, work, education,
finances, legal problems, spirituality)
• Dimensions of Substance Abuse
1. 6-Month Time-Line Follow-Back
Calendar
2. Substances abused & route of
administration
3. Patterns of use
4. Situations in which abuse occurs
5. Reported motives for use
• Social
• Coping
• Recreational
• Structure/sense of purpose
6. Consequences of use
Evaluating Social Factors
Associated with Substance
Abuse
• Does person have non-substance abusing
peers?
• Can person resist offers to use substances?
• Is the person lonely?
• Can the person initiate and maintain
conversations?
• Is person able to get others to respond positively
to him/her?
• Can the person express feelings? Resolve
conflicts?
Common Symptoms
Associated
with Self-Medication
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Depression, suicidal thoughts
Anxiety, nervousness, tension
Hallucinations
Delusions of reference & paranoia
Sleep disturbance
Mania/hypomania
Recreational Skills and
Substance Abuse
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What does the person do for fun?
Hobbies?
Sports?
What is person’s involvement with others in
recreational activities?
• Does the person not participate in activities
which he/she previously did?
Functional Analysis
• Goal: To identify factors which influence or control
substance use behavior
• Characteristics of Useful Functional Analyses
1. Focus on behaviors, NOT stable traits
2. Constructive, NOT eliminative
3. Contextual, NOT mechanistic
4. Examines maintaining factors, NOT etiological
factors
5. Leads to hypotheses that can be tested by
treatment & modified, NOT theories that remain
unchanged regardless of outcome
6. Change usually doesn’t happen magically on its
own
•Constructing a Payoff Matrix
1. List advantages & disadvantages of using
substances, & advantages & disadvantages of
not using substances in Payoff Matrix
2. Use all available information from functional
assessment
3. Consider advantages & disadvantages from the
client’s perspective
4. View different reasons listed as hypotheses
about maintaining factors, not established
facts; reasons may change as new information
emerges
5. If client is using, the pros of using & cons of
not using should outweigh the pros of not
using and cons of using
Pay-Off Matrix
Using Substances
Advantages
Disadvantages
Not Using Substances
Common Advantages and Disadvantages of Using
Substances and Not Using Substances
Using Substances
Not Using Substances
Advantages
Feels good
Acceptance & friendship when using with peers
Decreased social anxi ety
Feel "normal" when using with others
Escape from b elief one is a "failure" or has not
lived up to expectations
Relief from d epression or anxiety
Reduction or distraction from h allucinations
Help getting to sleep
Improved attention & concentration
Decreased medica tion side effects
Something to look forward to
Reduction in craving or withdrawal symptoms
Better relationships with significant others
Stable & independent housing
Improved control & stability of psychiatric
illness
Financial stability & control over one's
money
Stay out of jail/prison
Minimize d exposure to infectious diseases
& better management of medical illnesses
Reduced exposure to trauma
Improved ability to pursue goals & meet
major role obligations (worker, student,
spouse, parent)
Better social relationships, including
intimate relationships, with people who
really care
No physical dependence
Disadvantages
Conflict with significant others
Housing instability & homelessness
Relapses & rehospitaliza tions
Financial problems
Legal problems
Infectious diseases & other me dical illnesses
Increased exposure to trauma
Inability to pursue goals & meet major role
obligations (worker, student, spouse, parent)
Physical dependence leading to need for greater
amo unts
Sociopathic or crimi nal socia l network
Lac k of an intimate relationship
Increased hallucinations or paranoia
Lac k of positive feelings
Awkwardness or peer p ressure from friends
who use substances
Social i solation because no friends who
don't use
Social an xiety
Feel "abnormal" because of stigma from
mental illness
Confrontation with belief that one is a
failure
Persistent depression or anxiety
Distress due to hallucinations
Poor attention & concentration
Troubling medication side effects
Nothing to do or look forward to
Cravings or withdrawal symptoms
Examples of Interventions Based on
the Payoff Matrix
Using Subs tances
Not Using Substance s
Advan tages
Naltr exone
Disulfir am
Contingen t reinforcement
Comm unit y reinforcement
Motivationa l i ntervie wing
Dec isi ona l balance me thod
Educa tion abou t dua l dis orders
Persua sion g roups
Disadvan tage s
Disulfir am
Financ ial paye eship
Cond iti ona l discha rge from
psychiatric hosp it al
Probation or parole cond ition
Skil ls training for social
competence
Identifying new social out le ts
Teaching skill s for coping
wit h d ist ressful symptoms
Pharmacological treatment of
distressful symp toms
Deve loping alt ernative
recreationa l activities
Creating new & meaning
pursuit s (e.g., work , schoo l,
parenting)
Teaching strategies for coping
wit h cravings
Treatment Planning
• Goals: To determine which interventions are
most likely to be effective and how to
measure outcome
• Steps
1. Engage the client and significant
others
2. Assess motivation to change
3. Select target behaviors,
thoughts, emotions to change
4. Identify interventions to address
targets: select at least 1 strategy to enhance
motivation & 1 strategy to address needs
currently met by substance use
5. Choose measures to assess
effects of intervention
Treatment Barriers
• Historical division of service and training
• Sequential and parallel treatments
• Organizational and categorical funding
barriers in the public sector
• Eligibility limits, benefit limits, and payment
limits in the private sector
Integrated Treatment
• Mental health and substance abuse
treatment
 Delivered concurrently
 By the same team or group of
clinicians
 Within the same program
 The burden of integration is on the
clinicians
Other Features of Dual
Disorder Programs
• Assertive outreach
• Stage-wise treatment: engagement,
persuasion, active treatment, and relapse
prevention
• Long-term commitment
• Comprehensive treatment
• Reduction of negative consequences
What are the Stages of
Treatment?
1. Engagement, persuasion,
active treatment, and relapse
prevention
2. Not linear
3. Stage determines goals
4. Goals determine interventions
5. Multiple options at each stage
What Do We Do During
Engagement?
• Goal: To establish a working alliance
with the client
• Clinical Strategies
1. Outreach
2. Practical assistance
3. Crisis intervention
4. Social network support
5. Legal constraints
What Do We Do During
Persuasion?
• Goal: To motivate the client to address
substance abuse as a problem
• Clinical Strategies
1. Psychiatric stabilization
2. “Persuasion” groups
3. Family psychoeducation
4. Rehabilitation
5. Structured activity
6. Education
7. Motivational interviewing
What Do We Do During
Active Treatment?
• Goal:
 To
reduce client’s use/abuse of substance
• Clinical Strategies
1. Self-monitoring
2. Social skills training
3. Social network interventions
4. Self-help groups
5. Substitute activities
6. Close monitoring
7. Cognitive-behavioral techniques to
address:
High risk situations
Craving
Motives for substance use
Socialization
Persistent symptoms
Pleasure enhancement
What Do We Do During
Relapse Prevention?
• Goals:
 To maintain awareness of vulnerability and expand
recovery to other areas
• Clinical Strategies
1. Self-help groups
2. Cognitive-behavioral and supportive interventions
to enhance functioning in:
 Work, relationships, leisure activities, health, and
quality of life
Relapse Prevention
Strategies
• Construction a relapse prevention plan:
– Risky situations
– Early warning signs
– Immediate response
– Social supports
– Abstinence violation effect
Recovery Mountain
• Combat demoralization related to
relapses
• Reframe relapses as part of road to
recovery
• Don’t loose sight of gains made
between relapses
• Learning experience, modify relapse
prevention plan
Stages of Substance Abuse
Treatment
1. Pre-engagement: No contact with a counselor.
2. Engagement: Irregular contact with a counselor.
3. Early Persuasion: Regular contact with a
counselor, but no reduction in substance abuse.
4. Late Persuasion: Regular contact with a
counselor and reduction in substance use (< 1
month).
5. Early Active Treatment: Reduction in
substance use (> 1 month).
6. Late Active Treatment: No abuse for 1-6
months.
7. Relapse Prevention: No abuse 6-12 months.
8. Remission: No abuse for over one year.
Research on Integrated
Treatment (IT)
• 26+ RCT or quasi-experimental studies of IT
(reviewed by Drake et al., 2004)
• 3/4 studies of brief motivational interviewing
interventions showed positive effects
• 6/7 studies found group intervention better than 12step or standard care
Research on IT (Cont.)
• Family intervention: no RCTs examining
family treatment alone
• Comprehensive IT: 2 RCT & 1 quasiexp. study favor comp. IT over
treatment as usual
• Intensity: more intensive IT produces
slightly better outcomes (e.g., Drake et
al., 1998)
Drake et al. (1998)
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203 clients (77% schizophrenia)
ACT vs. standard case management (SCM) (both IT)
3 year follow-up
ACT better than SCM in alcohol severity & stage of
treatment
• No differences in hospitalization, symptoms, quality
of life
NH Dual Diagnosis Study
Proportion of Days in Stable Community Housing
1.0
0.9
0.8
0.7
Beginning
6 months
12 months
All DD Patients (N = 203)
18 months
24 months
30 months
36 months
Patients in Recovery (N = 54)
1. Proportion of days in stable community housing (regular apartment or house, not in hospital, jail,
homeless setting or doubling with friends or family) increased for all dual diagnosis clients.
2. They increased more rapidly for persons in recovery (no substance abuse for at least 6 months).
NH Dual Diagnosis Study
Percentage of Persons Hospitalized
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
Beginning
6 months
12 months
All DD Patients (N = 203)
18 months
24 months
30 months
36 months
Patients in Recovery (N = 54)
1. Percentage of persons hospitalized during each six months declined
significantly for all clients.
2. It declined much more for those in recovery.
Fidelity to IT Model
Improves Outcome
Limitations of Research
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Lack of standardization of treatments
No or limited fidelity assessment
No replication of program effects
Unclear or variable comparison conditions
Avoiding the
Blame/Demoralization Trap
Don’t blame the client for substance abuse or
relapses because:
 Substance abuse is a disorder for which
clients are no more responsible than their
primary psychiatric symptoms
 Clients with most severe substance abuse
need professional help the most; many others
improve spontaneously
 Remember that the clients are doing the best
they can
To avoid demoralization:
 Remember: integrated treatment works in the
long run
 There is usually no obvious “best solution”
 Adopt a collaborative-empirical approach to
treatment
 View relapses as an inevitable part of the
recovery process
 Develop a case formulation based on a
functional analysis to guide treatment