Treatment Approaches for the Dually Diagnosed:
The Problem of Co-occurring Addictive and Mental Disorders
Bill Burns-Lynch, MA, CPRP
March 1997
Introduction
The 1980's brought into the mental health literature a population defined at the time as young chronics. These patients were characteristically difficult to serve and substance abuse was clearly associated with their treatment resistance (Osher, F. & Drake, R., 1996). During the 1990's, increasing concern rose among mental health professionals regarding this population of dually diagnosed patients. This paper will use the term dually diagnosed to refer to this group of patients with severe and persistent mental illness (major psychotic disorders such as in the schizophrenia spectrum, bipolar disorders, and severe unipolar depressive disorders) and co-existing drug and alcohol problems.
Concern for this population has grown from an awareness of two consistent findings in the literature, namely: there is an increased prevalence of substance abuse and dependence in persons with severe mental disorders, and there are consistent correlations between substance disorder and increased psychiatric symptomatology with poor prognosis and social adjustment among persons with mental illness (Osher, F. & Drake, R., 1996).
Studies have found a higher rate of drug and alcohol problems among the psychiatrically disabled than within the general population. For example, Pepper (1991) reports that patients under 40 years of age who are being admitted or readmitted to a psychiatric hospital because of an acute episode have alcohol or intoxicating drugs in their brain 75% -80% of the time. As many as 64% of inner city psychiatric inpatients have been reported to have co-occurring substance abuse diagnoses (Silberstein, C., et al., 1994). Psychiatric outpatients have rates of substance abuse ranging from 17% to 53%, with psychiatric emergency departments experiencing the highest rate; psychiatric inpatients have demonstrated a higher rate ranging from 32% to 63%. Additionally, younger and more seriously ill patients have higher rates of dual diagnosis (Batki, S., 1990).
In a sample of 200 homeless mentally ill adults in West Philadelphia, Burns-Lynch and Samuel (1996) found that upon initial intake to an intensive case management and drop-in center program 78% of program participants reported a history of drug use or abuse, and 73% reported a history of alcohol use or abuse. Additionally, 57% reported a history of prior drug/alcohol treatment, and 60% reported to be clean and sober at intake. It is important to note here that all of the assessments of substance abuse at intake were based on self-report. Numerous studies show, however, that there are many positive urine tests among psychiatric patients who deny drug/alcohol use (Drake, Mueser, Clark, &Wallach, 1996). Therefore the percentage of co-morbidity may actually be higher than the numbers indicate for this sample. It is also likely that the percentage of clients who were clean and sober at time of intake is actually smaller than the numbers indicate.
Osher, F. & Drake, R., (1996) suggest that the most compelling evidence comes from the Epidemiologic Catchment Area (ECA) study (Regier, D., et al., 1990) where psychiatric and substance use disorders were assessed in more than 20,000 persons living both in the community and in other various institutional settings. Individuals with severe mental illness were at increased risk for developing drug or alcohol use disorders over their lifetime. Individuals with schizophrenia were more than four times as likely to have had a substance use disorder during their lifetime as were persons in the general population. Individuals with bipolar disorder were more than five times as likely to have had a co-existing diagnosis (Osher, F. &Drake, R., 1996). Forty- seven percent of individuals with a lifetime diagnosis of schizophrenia or schizophreniform disorder had met criteria for some form of substance abuse or dependence (Drake, McLaughlin, Pepper, & Minkoff, 1991).
As noted above, individuals dually diagnosed have increased manifestations of negative outcomes associated with their co-existing substance problems. Osher and Drake (1996) provide the following examples of negative outcomes in their review of the literature: increased vulnerability to re-hospitalization; more psychotic symptoms; greater depression and suicidality; incarceration; inability to manage finances and daily needs; housing instability and homelessness; noncompliance with medications and other treatments; increased vulnerability to HIV infection; lower satisfaction with familial relationships; increased family burden; and higher service utilization costs.
A Brief History
The increased prevalence of dual disorders among the mentally ill must be placed within the sociohistorical context during which the problem arose. To begin with, a generation of young chronically mentally ill adults has grown up in the era of deinstitutionalization. This cohort of young chronics are quite similar to cohorts of previous years, that is to say, with few skills, myriad deficits, diverse symptoms, and considerable need for psychiatric and supportive services (Drake, R., et al., 1991). However, deinstitutionalization was more than just a process of state hospital depopulation, it was also a philosophy that asserted community-based care was a more therapeutic and compassionate alternative to caring for the seriously mentally ill (Bachrach, L, 1992). Thus, as long time residents of state hospitals were transferred into the community, so too the newly psychiatrically diagnosed were kept in the community for treatment where alcohol and other drugs were more than abundant (Pepper, B., 1991).
Secondly, the movement toward deinstitutionalization in the United States also coincided with the 1960's counterculture revival of psychoactive drugs (Drake, R., et al., 1991). Social acceptance and experimentation with illegal drugs was soaring dramatically in the United States during this time period. For the first time in our history then, an entire generation of young people with mental illness has grown up within this era of deinstitutionalization, making access to alcohol and other illicit drugs more than readily available to them (Drake, R., et al., 1991). Indeed, it can be argued that the dually diagnosed individual may have had more easy access to alcohol and drugs than he or she may have had access to competent and compassionate treatment.
Perhaps the fate of the now dually diagnosed would have been different had the process of the deinstitutionalization of our state hospitals done more than discharge hundreds of thousands of seriously mentally ill people to the street in an irresponsible manner, with a lack of community residential and therapeutic supportive services (Pepper, B., 1991). Instead however, new state hospital policies shortened the length of stay for newly diagnosed patients being admitted for treatment of psychotic episodes, and community mental health centers failed miserably in their attempts to make service provisions for this population (Torrey, E., 1997). Given the painful social disability and stigma, and the often frightening, paranoid, and delusional world of psychotic hallucinations, it is hardly surprising that the mentally ill would turn to drugs and alcohol for relief from their symptoms. Pepper (1991) states that while intoxication with alcohol and other illicit drugs may temporarily alleviate the extreme distress experienced by the mentally ill, in the long run when the drug wears off, the symptoms that fared temporary relief only tend to worsen. Obviously the solution is to re-intoxicate, leading to the devastating cyclical nature of the dual disorder.
Treatment for Mental Health and Drug/Alcohol Disorders
Compounding the problems brought about by the sociohistorical context for the mentally ill was also the historical separation, both on a federal and a local level, of treatment services for mental illness and addictive disorders. Osher and Drake (1996) state that the treatment of addictive disorders has been alternatively embraced and shunned by the health care system in general, and mental health providers in particular. In the early 19th century addictive disorders were first treated in medical settings. The disease theory of addiction postulated by Benjamin Rush helped to provide for the involuntary treatment of the addicted in asylums at this time (Osher and Drake, 1996). However, by the beginning of the 20th century, when no medical intervention had been found to cure addictive disorders, and costs to run these asylums continued to rise, public support diminished as did the existence of the asylums (Osher and Drake, 1996).
By the 1920s and the 1930s, the growth of successful community based programs such as Alcoholics Anonymous and Narcotics Anonymous promoted the non-institutional care for the addicted person, and diverted the treatment of addictions from the field of medicine and mental health, establishing a parallel system of care (Osher and Drake, 1996). The 1960s brought a renewed interest in the disease concept of alcoholism (and other addictive disorders). Coupled with an increased social tolerance of drug experimentation, and an increased public awareness of the extent of addictive disorders, there was an increased demand for addiction treatment services. Again the medical community took a dominant role and the norm of treatment became the provision of short-term inpatient treatment followed by long-term involvement in the AA and NA fellowships (Osher and Drake, 1996). Osher and Drake make the point that even though the treatment of addictive disorders returned to the medical community, it was disassociated from treatment for mental illness. This separation proved to be devastating for the newly diagnosed mentally ill and the deinstitutionalized mentally ill who turned to drug and alcohol use.
There were also federal organizational and legislative parallels serving to reinforce this separation of treatment services. The role of the federal government has been formidable, and while interesting, it is beyond the scope of this paper. Briefly however, with the creation of the Mental Health Act of 1946, the National Institute of Mental Health (NIMH) was mandated to develop mental health, alcohol, and drug initiatives and policies for the country (Osher and Drake, 1996). The first formal separation of NIMH came as an unintended result of the Comprehensive Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 which created the National Institute on Alcohol Abuse and Alcoholism (NIAAA); and the Drug Office and Treatment Act of 1972 which also established the National Institute on Drug Abuse (NIDA, [Osher and Drake, 1996]). While the enactment of this legislation and the creation of these agencies was generally a positive development for the treatment of drug and alcohol disorders, they also had the effect of formally separating mental health services from drug and alcohol services within NIMH, thereby creating competition for funding sources.
The federal government reorganized and restructured these administrative offices on two other occasions. The first during the Reagan years which was accompanied by the federal government issuing block grants (after cutting funding by a third) to states in an effort to control federal costs as well as to give control to individual states as to how to best distribute federal dollars for treatment. Secondly, 1992 brought us the Substance Abuse and Mental Health Services Administration (SAMHSA) with the Center for Substance Abuse Prevention, the Center for Substance Abuse Treatment, and the Center for Mental Health Services (Torrey, E.F., 1997). This legislation served to further the divide between mental health treatment and treatment for addictive disorders because it separated the mental health portion of the block grant formula from the drug and alcohol portion, again setting up competition for funding streams (Torrey, EF., 1997).
Finally, state and local governments throughout this period also organized themselves along the same lines as the federal government. In fact, Osher &Drake (1996) report that the National Association of State Mental Health Program Directors has documented a progressive shift over the last twenty years to administer addiction services separately from mental health services. While federal and state dollars were increasingly cut from service and treatment budgets, service agencies responded by limiting their eligibility criteria for treatment services, and the dually diagnosed found themselves either excluded from access to addiction treatment agencies because of their psychiatric problems, or excluded from access to mental health treatment agencies because of their addiction issues. At best, treatment for these individuals was defined as a parallel process between the addiction and mental health agencies, however with little or no coordination of services between the treatment providers, and often times with the dually diagnosed individual having to navigate this system of care on their own. Given the above realities, it is little wonder that there was such an increase in the prevalence of dual disorders among the psychiatrically ill in this country.
Traditional or Parallel Treatment for the Dually Diagnosed
Current traditional treatment approaches stress the necessity of providing intensive and specific treatments for both illnesses concomitantly, combining the resources of mental health and addiction service systems (Ridgely, 1991). However, as noted above, structural and organizational barriers continue to inhibit treatment efficacy. Research describing the longitudinal course of illness then, is limited as such because many dually diagnosed individuals are in and out of each treatment modality, often determined non-compliant with treatment or labeled treatment failures. Additionally, most studies have followed clients for no more than 12 to 18 months, and other long- term studies of mental illness have rarely assessed addictive disorders (Drake, R., et al., 1996).
Follow-up studies in this context do confirm that dually diagnosed individuals experience poorer psychosocial adjustment than do those individuals diagnosed with severe mental illness alone. Drake, et al. (1996), in their review of the literature, report that homelessness and institutionalization are the most frequently measured indicators of psychosocial adjustment; and short-term follow-up studies indicate that substance abuse disorders tend to persist among those with severe mental illness.
Disagreement over primary diagnoses, the use of psychotropic medications in treating psychotic disorders versus remaining drug free, and treatment personnel issues aside (specifically trained addiction counselors versus psychologists, psychiatrists, social workers), there are significant treatment philosophy differences between the traditional mental health system and the traditional substance abuse system that also inhibit treatment efficacy for the dually diagnosed patient.
Minkoff (1991) describes these differences as:
- Care vs. Confrontation;
- Abstinence-Oriented vs. Abstinence-Mandated Programs; and
- Deinstitutionalization vs. Recovery and Rehabilitation.
Care vs. Confrontation
Most mental health systems providing treatment for the seriously and persistently mentally ill have organized around the principle of case management (community support program model). Client assessment in a variety of life domains identifies individual needs and case managers are charged with the task of meeting client needs through linking with various community social service agencies. In this system, case managers will take responsibility for psychiatrically impaired clients who may not have the capacity to recognize their need for help and provide services for the client so as to minimize negative consequences for the client.
In contrast, however, addiction treatment and AA philosophy place emphasis on individual responsibility and individual motivation (Minkoff, 1991). Twelve-step programs tend to educate individuals as to what is available to help them. It is up to the individual to motivate him/herself and ask for what it is s/he needs. Clients are confronted by the negative consequences of their behavior as a motivating force. When clients don't ask for or accept help, the addiction counselor's role is to detach, thereby making the client assume responsibility for his/her behavior (Minkoff, 1991). However, the mentally ill experience increased rates of joblessness, decreased rates of social contacts, and in many instances poor social status. This being true, the dually diagnosed patient may not be motivated by negative consequences in these domains.
Abstinence-Oriented vs. Abstinence-Mandated Programs
Addiction treatment and certainly AA philosophy advocate an abstinence-mandated program. Indeed, traditional addiction treatment programs would argue that they would lose their credibility as well as their effectiveness if they mandated anything less than total abstinence (Minkoff, 1991). While client-therapist relationship is important in addiction treatment, often times a willingness on the patient's part to remain abstinent will dictate whether the client remains in treatment, or is admitted back into treatment after relapse.
However, advocates in the community support model would argue that positive outcomes for clients are related to the stability of the treatment relationship. Requiring total abstinence from the start for most dually diagnosed patients may have the effect of discouraging or even preventing engagement in the treatment process (Minkoff, 1991). Engagement in relationship and treatment would be much better served if abstinence was encouraged as a goal. Incremental steps in the decrease of amount and frequency of substance use (a harm reduction approach) can in the long run lead to more long-term behavioral change (Carey, 1996). Additionally, dually diagnosed patients service utilization records indicate a cyclical nature of crisis interventions, and engagement in treatment can be enhanced by the case manager providing specific crisis relieving interventions (sometimes basic necessities such as food, clothing, and shelter) which can serve to develop relationship between case manager and client (Ridgely, 1991). Developing a strong supportive relationship with someone who is paranoid and delusional is difficult to do in a confrontational style.
Deinstitutionalization vs. Recovery and Rehabilitation
Finally, addiction treatment is predicated on the concept of long-term recovery. Often times in order to bring about a more consistent long-term sobriety, clients seek treatment in more restrictive and intensive settings, i.e., recovery houses, and inpatient treatment facilities (Minkoff, 1991).
Deinstitutionalization on the other hand has been characterized by client care in the least restrictive setting with the measurement of success being an increased number of days in the community for the patient, i.e., decreased inpatient service utilization.
The dually diagnosed client then can be bounced back and forth like a ping pong ball between treatment systems (Ridgely, 1991). Perhaps the major limitation of this type of treatment is that increased pressure is placed on case managers (in some instances) and certainly on clients to maintain service continuity through numerous service interruptions experienced by the client. This type of treatment has numerous trap doors for the dually diagnosed client which may simply set up the client for failure and thereby exacerbate psychiatric symptomatology and sabotage therapeutic relationship. An integrated or hybrid treatment approach is clearly a more appropriate and efficacious treatment option for the dually diagnosed client.