Integrated Treatment for Dual Disorders



good afternoon and welcome to the Center for psychiatric rehabilitation webcast series I'm Sally Rogers the director of research at the center and it's my pleasure to introduce to you dr. Kim user professor from Dartmouth University and a preeminent researcher in the field of mental health and psychiatric disability for many of you dr. Moussa requires no introduction because of the many contributions he is made to our field especially for people with mental illness and substance abuse disorders however by way of introduction I'd like to review with you some of the many contribution tribution that dr. Muser has made dr. Muser is a licensed clinical psychologist with a doctorate in psychology from the University of Illinois at Chicago obtained in 1984 from 1984 until 1990 from 1987 rather until 1984 he was a professor at the University of Pennsylvania Medical School in 1994 he joined the Dartmouth faculty and is now a professor in the department's of psychiatry and community and family medicine Kim's areas of interest include the psychosocial treatment of severe mental illness post traumatic stress disorder and dual diagnosis he has published over 150 peer-reviewed articles approximately 100 and box and manuals and has given hundreds of presentations to professional groups dr. Mueller also serves on the editorial board of several professional psychology journals and is involved in many other psychologically oriented activities on a personal note the Center for psychiatric rehabilitation has been very fortunate to count dr. Muser as a colleague and advisor he is always insightful helpful thoughtful and forthcoming with information which has been which has been a great benefit to us at the center without further ado I'd like to introduce you to dr. Kim user who will present this webcast on the integrated treatment of dual diagnosis thank you thank you very much for the introduction it's always a wonderful to be here at Boston University so many good things have started here and continue to be done here I'm gonna be a little bit fast and my talking today because I get to try to cover a little bit of everything and with that in mind let's start off with a little preview of what it is that I'd like to cover I'm going to start off and I'm going to talk quite briefly about the effect of substance use problems on people with severe mental illness in order to make sure that we're all on the same page in terms of understanding the scope of the problem and then going to talk a little bit about limitations of traditional parallel or sequential approaches approaches to working with people with dual disorders that don't attempt to truly integrate the services for the treatment of both of the disorders then I'm going to lay out the principles of integrated treatment beginning with the definition of what integrated treatment is and then talking about core components of integrated treatment programs in particular I'm going to focus on the component of stage-wise treatment treatment that's tailored to individuals motivation to change and that that motivation may depend on the person's mental state in terms of where they're at in terms of learning how to manage their psychiatric illness and learning how to manage in to conquer their substance use problems then I'm gonna shift gears and talk a little bit about research you talk about controlled studies of integrated treatment for dual disorders and then I'm gonna talk about a little bit about some new areas I'm gonna talk about a family intervention program that was has recently been developed and it's currently being evaluated I'm also going to talk a little bit about pharmacological treatment strategies then we'll try to take a few questions so with all that in mind you can see why if I speak a little bit fast I hope that you'll forgive me but for those of you who miss some of the things that I say or who would like more information first of all this PowerPoint presentation will be made available through the web so you can download that and look at that and then second of all if you want lots more detail it is now available in a book that just came out last year published by Guilford press that is widely available in paperback and at a pretty cheap price which is nice so with that having been said let's talk about what probably everybody already knows which means that we don't need to get into a lot of detail about it but that is the fact that substance use and abuse is associated with the worst course of psychiatric illness with respect to pretty much every possible domain of functioning there's tons of research showing that the use of substances alcohol cannabis cocaine opiates and and so on is associated with the precipitation of relapses and rehospitalization can lead to significant economic problems as consumers often spend the limited money they have on substances it can lead to great amounts of family conflict and a high level of strain in close relationships with other people it can lead to economic problems I mentioned economic problems but medical problems housing problems and of course legal problems because of the unlawful nature of much drug abuse and because the disinhibited effects that substance use has one of the up shots of substance use in the population people with severe mental illness is an increased vulnerability to trauma and also to infectious diseases in fact what we find is that people with severe mental illness are an increased risk to a wide range of infectious diseases but most significantly to hepatitis C which of course is the leading cause of liver transplants in this country and the number one predictor or the number one contributing factor to infectious diseases is drug use so there are many many problems associated with substance use in terms of the exacerbation of psychiatric illness and efforts to address substance abuse in this population of course are guided by the goals of trying to improve the long term course of the illness and to empower consumers to take back control over their lives so for all of these reasons addressing substance use problems and people with severe mental illness is of the highest priority well let's talk just for a minute or two about barriers to treatment problems that consumers have have often experienced in traditional treatment systems for psychiatric and substance use problem traditionally approaches to treating dual disorders comprised primarily of either parallel approaches or sequential approaches a parallel approach is where you would have a substance abuse service located in one setting and mental health services located in another setting typically funded by separate funders with different eligibility criteria and the expectation is that people with dual disorders are supposed to get treatment for both their disorders but from those separate agencies so the services are delivered in theory at least in a parallel fashion there are many problems with parallel service deliver perhaps the most important problem is the lack of coordination to say nothing of the lack of actual access to both services in fact sometimes substance use services or mental health services actually prohibit the provision of services to people who are receiving services for one of those other disorders there are other problems too in terms of accessing those services and even when services are accessed often there's a lack of integration between the two and sometimes services can be actually in conflict with one another so there are problems in terms of parallel approaches both in terms of accessing services in terms of delivering both mental health and substance use services in a cohesive and integrated fashion the sequential treatment approach refers to trying to treat one disorder first followed by the treatment of another disorder and the idea is that if you try to treat the so called primary disorder and nobody can really tell what's primary and what's secondary but if if you could tell which was primary which was more important would it make the other disorder go away and so efforts to treat one disorder followed by another disorder are based on the assumption that when you have people with co-occurring or dual disorders often one disorder is more primary than the other so the idea being oil you have a person with bipolar disorder and they have a frequent bouts of drinking if we could stabilize the bipolar disorder maybe the drinking problems will go away or if we have somebody with schizophrenia who uses some substances and those substances exacerbate symptoms such as of the use of cannabis well gee if we can get the person to stop using cannabis maybe it wouldn't exacerbate their schizophrenia it would be well-managed now the trouble with sequential treatment approaches is that it fails to take into account that psychiatric illnesses and substance use disorders interact with one another that it's extremely difficult to successfully manage bipolar disorder without addressing concurrent substance use problems and similarly it's extremely difficult to address substance use problems in somebody say with schizophrenia without attempting to address the schizophrenia so in fact the trouble with sequential treatment approaches is that they don't take into account the fact that the we have one disorder feeds upon and can worsen the other disorder and that makes it inherently more difficult to successfully treat one disorder without attending to the other disorder now the problems with sequential and parallel treatment approaches were pretty well recognized actually by the the late 1980s in the early 1990s and those problems led to the development and formulation of models of integrated treatment for co-occurring or dual disorders well when we talk about integrated treatment and there are a number of different models out there but in truth the models probably share or have more in common than then they differ from one another when it comes to defining integrated treatment at the most at the most basic level an integrative treatment program can be defined as one in which the mental health services or the mental health problems and the substance use problems are treated at the same time by the same clinician or by the same team of clinicians and which those clinicians assume the responsibility for integrating the treatment of the two disorders now the notion of integrating the treatment for the two disorders actually can come quite naturally if the treatment focuses on and examines the natural interactions between mental illness and substance use problems and just to give you a few examples we know that sometimes people with major mental illnesses have difficulties establishing and maintaining close relationships with other people and yet they like everyone else have a need to have love and closeness and and friendship and acceptance in their lives and sometimes people get those needs met in part through social contacts with people who have substance use themselves and that can lead to substance use problems so I asked you if we help that person develop alternative social contacts and better social skills and ways of connecting with people other than through using substances are we treating the psychiatric illness or are we treating the substance use problem and clearly we're treating both and there are many other examples for example sometimes people use substances in order to cope with psychiatric symptoms and yet we know a tremendous amount about how to help people cope more effectively with symptoms so if we help people cope more effectively with symptoms or again are we treating the substance use problems are we treating the psychiatric illness and the answer is that we're treating both so in effect integrated treatment means treating both of the disorders at the same time by the same team of clinicians with a particular eye towards understanding the interactions between the disorders well that having been said what are some features of integrated treatment programs I mean once you're integrating the services you still need to provide a certain core set of services what I'm going to do is I'm going to describe basic fundamental ingredients that integrated dual disorder programs strive to incorporate or to the extent that they incorporate these ingredients those programs tend to be more effective now the specifics of the programs vary it's typical for programs to provide a variety of different psychotherapeutic formats ranging from individual work to group work to family work but overall what many programs seek to do what what the most effective integrated dual disorder programs seek to do is to provide some amount of assertive outreach and I'm going to go through each of these and in a moment meaning the provision of services and in consumers natural living environments they have a long-term commitment to providing services over an extended period of time and don't impose artificial time constraints their comprehensive and that they address the wide range of needs that consumers have they focus on taking advantage of opportunities to address and to reduce the negative consequences of substance use problems never allowing a person or or or assuming the philosophy that it's best for a person to hit rock bottom and then last of all programs that are most effective have a sensitivity to the individual stages of change the the individual motivation that a person has to change his or her behavior and by having that sensitivity programs are most effective at being able to optimize outcomes by matching interventions to consumers stages of change or stages of treatment let's go into each of these in a little bit more detail a sort of outreach of course refers to the provision of services in consumers natural environments most typically in their homes and an apartment the home of a family member it could be at a coffee shop or at a park bench or some other kind of a public place or a library or YMCA the primary reason that is sort of outreach is important is that many consumers with dual disorders are not active participants in treatment or they may have sporadically be involved in treatment but many of them especially during the height of substance use episodes are not actively engaged in treatment and if you want to engage people and develop a working relationship and and begin the process of of motivating people and instilling hope often you need to do it on their terms in settings that they're most comfortable with and that often means in the community another advantage or another reason why sort of outreach is important is that it provides you with more opportunities for engaging individuals in the consumer social network there's a lot of research already showing that the more people in someone's social network who use substances the more difficult it's going to be for that person to attain sobriety and at the same time we know that family relationships are tremendously important to people with major mental illnesses on and also for people when they have an active substance use problem so being able to go out in the community and connect with people in their natural living situations provides additional opportunities for connecting with those significant others a final advantage of doing a sort of outreach is it often provides you with important information about the environment in which consumer lives and may provide helpful information about the course of the dual disorders as well long-term perspective is is based on a recognition that severe mental illnesses are often long-term even though many individuals attain recovery in the long term many individuals continue to have a need for ongoing services and in the same way although for some people substance use problems may be time limited for other individuals it's often a chronic relapsing condition people may have a relapse after significant periods of sobriety and other people still may not even achieve a full remission of their substance use problems and in the same way that that an ongoing commitment to working with a person and and addressing their needs and in ways that they define important is critical for the management of a psychiatric illness it's also critical when the person has a co-occurring substance use disorder and that is an impression Stu imposing artificial time constraints on the provision of services comprehensive treatment is based on a recognition that people with co-occurring disorders have a wide range of needs and those needs run from the need to improve their ability to cope with persistent symptoms whether it's hallucinations or delusions anxiety depression sleep problems post-traumatic stress disorder symptoms and and the like people have a need for for help and improving their their capacity to cope effectively with symptoms and to reduce the distress that that symptoms caused people have a need to have good quality relationships with their family members may have a need to help to overcome the debilitating effects of traumatic experiences that they may have had during childhood and and in adolescence and and after they developed a mental illness people have many other needs as well they have medical needs which we've already briefly talked about they may have needs in terms of of parenting skills especially women with a severe mental illness and a dual disorder often have children and those children are may be vulnerable to neglect and and yet those those mothers have a tremendous desire to be good parents and and so they have a need for parenting skills there's a need for housing there's a need for from many other types of basic services and so an effective to create a treatment program for dual disorders it's one that addresses the wide range of functional needs as well as needs in terms of the the symptoms of the psychiatric illness and and basic social needs as well rather than being something that's that's narrowly focused on substance use behavior and reduction of harmful consequences reduction of harmful consequences refers to efforts to try to minimize the negative effects of substance use on a person those effects could be for example we know that use of of dirty needles can lead to infectious diseases so needle exchange programs are a form of reduction of harmful consequences teaching safe sex behaviors to individuals who may exchange sex for money or for substances would be another example of the reduction of harmful consequences there are a number of reasons for thinking that reduction of harmful consequences is an important component of any integrated treatment program first of all we know that many people with co-occurring disorders improve gradually over time now some people see abstinence as a goal and endorse as a goal from early on and strive to achieve that but for many other people the pathway to abstinence and sobriety is through a gradual reduction and therefore the need and and the desire to reduce the harmful consequences becomes critical so they're able to be around and to be working towards sobriety in the long run because many of the consequences that we're talking about we're reducing ultimately can lead to premature mortality another important reason for for using strategies that attempt to reduce harmful consequences of substance use is that it represents a way or it is a way of establishing a relationship with someone it demonstrates caring to the other person and and that caring can form the beginning of a bond a therapeutic relationship with the individual that may over time lead to the development of motivation to to work in a concerted way towards reducing one's substance use problems there are many examples of strategies for reducing the harmful consequences of substances I mentioned needle exchange and and safe sex lessons I also think that that family intervention can be conceptualized as an approach aimed at reducing harmful consequences and and the reason is that we know the people with co-occurring disorders impose or or create greater amounts of stress in the home and we also know that when the stress in the home becomes overwhelming sometimes what happens to that is that family members are unable to cope with that stress and eventually what they withdraw their their caregiving their their psychological and and economic and and other kinds of investment in the consumer and the withdrawal of that support is associated with the worst course of illness and in fact research by Rob and Clark has shown that family involvement is directly related to consumers needing lower levels of professional involvement for their dual disorders and is associated with a better outcome of the dual disorder so the early stage is a family intervention following the the engagement of the family in the treatment process are actually aimed more at reducing the negative effects of substance use on the family then trying to actually direct the substance use behavior at selfless use which is more of a longer-term goal so I think that is yet another type of strategy designed to reduce harmful consequences of of substance use and let's get now to the last of the different components of effective integrated treatment programs and that is the use of a stage wise treatment approach now the concept of the stage of the stages of change or stages of treatment is based on the notion that when people are in the process of changing a behavior in particular changing a behavior associated with health consequences so so the concept of of stages of change was has really been developed usually around or was developed mainly around health related behaviors such as smoking weight gain and and then applications to substance use problems the notion is that when people are are going about changing behavior that change process go through a series of discreet chain of discrete stages and that at each stage the person psychologically is at a particular place in that change process and understanding that change process can be important in terms of helping the person get to the next stage now the stage has changed where first described by James pore Chaska and have been tremendously influential in the rid of the psychotherapeutic field and those stages of change included pre contemplation and pre contemplation you're not even thinking about changing and then contemplation you're thinking about it but you're not changing and then preparation you're beginning to make plans to change and then behavior change where you actually undertake changes in one's behavior whether it's smoking drinking or or some other kind of behavior that you're beginning to change and then maintenance and so each of those stages of change represent psychologically different spaces in which the person resides for a period of time and an understanding that space becomes critical in terms of helping them get to the next stage now the stage is a change were adapted are at our research center by Fred oh sure and Lao Co fed about 15 years ago and they were adapted to refer to stages of treatment that people would dual disorders go through when they participate in professional based treatment for their disorders so the stages of change really map on to the stages of treatment but the differences are that the stages of treatment refer to the process of getting and being involved in professional help and the stages of treatment also have very direct implications for the selection of treatment strategies based on an individual's stage of treatment now the stages of treatment as I said map onto the stages of change and those stages include the engagement stage of treatment the persuasion stage the active treatment stage and the relapse prevention stage and what I'm going to do for each stage is to briefly walk through them to give you a little bit of a clinical intuition the idea behind each of those stages what what's what's unique about that stage and then I'm going to give you examples of strategies can be used to help people achieve the goal of that stage and for each stage I will identify a specific behaviorally based goal and it's very important that the goal is behavioral because what that means is that if you have a treatment team of individuals and you try to evaluate a person's stage of treatment you can have very very high reliability on that stage of treatment because it's behaviorally based you're not trying to intuit the person's internal motivation for change what you're doing is you're using specific behaviors to determine that person's level of motivation so let's walk through the different stages the idea of the engagement stage is that if you want to help somebody change their behavior you first need to have a therapeutic relationship with that individual and until you have a therapeutic relationship with that person you shouldn't be trying to change behavior so that's that's kind of the idea behind it now let's and and therefore end the goal of course is to establish a therapeutic relationship with the person okay so that's kind of the what I call the clinical intuition behind the stage now let's get to the behavior okay how do you behaviorally operationalize establishing a therapeutic relationship with someone well talk is cheap I mean people people say many things and maybe they're motivated maybe they're not there there are a lot of different payoffs for saying things that that you might actually have limited motivation to to pursue so we're very practical we define motivation and I've gotten into motivation I actually I'm getting into that the therapeutic relationship here we defined the therapeutic relationship as established when you're seeing the person on a regular basis it doesn't have to be you know a really really deep relationship but if you see the person on a regular basis let's say you're seeing them once a week for three or four or five weeks for all practical purposes they're engaged in treatment so rather than trying to look for a level or a qualitative aspect of that relationship which really becomes very very difficult to assess simply look at the frequency of contacts is how we define engagement okay well with that in mind what are some strategies for engaging people well if they're not coming into you and and often they're not that's where a sort of outreach comes critical you need to go out there and then of course the question becomes what do you do when you're going out there and and meeting and and working with individuals and and here's where I say I I kind of use what I described as that the Pavlovian conditioning approach to relationship formation which means that what you want to do is is go out there and meet with people in there on their own turf to make them feel comfortable and somehow by hook or by crook make them feel better that might have to do with helping people get very basic needs met like I'm housing clothing shelter it might have to do with with providing better medication management if a person's is helped to get or to take medications that that decreased distressful symptoms that's a very positive thing just listening and talking with the individual and providing validation can be very helpful also providing support to the social network can be helpful all of those are engagement strategies that can be helpful in terms of developing a working relationship with the individual sometimes legal constraints are also used such as when a person presents a grave threat to self or others and those legal constraints can can lead a person sometimes they can result and say it outpatient commitment to treatment or sometimes they may lead a person to be hospitalized and while those legal constraints need to be dealt with therapeutically they nevertheless represent an opportunity to develop a working relationship with the individual but the idea is that you shouldn't be trying to change their behavior before you have some kind of a working relationship established now once you have a relationship established meaning that you're seeing the person on a regular basis but the person's continuing to use some substances insofar as you can you can determine your in to the persuasion stage and what characterizes the persuasion stage is that you have this relationship but there's no real agreement in that relationship that you're working together to address the substance use problems you remember that you you reached out to them you established a relationship with them you didn't push the substance use issue and you didn't try to change their behavior in the engagement stage and so when you're into the persuasion stage once you've got that relationship the question becomes how can you motivate that person to become interested in reducing substance use or in achieving a sobriety and so the nature of the persuasion stage is that the goal is to motivate a person to begin working on their substance use problems which then leads to the the question of how do you know when somebody's motivated to work on their substance use problems and and this is where I began to actually talk about it a little bit earlier at the engagement stage of jumping the gun a little bit but the idea being that it's really hard to know based on what somebody says whether they're in fact genuinely motivated to work on their behavior change and therefore our practical approach has been to define motivation based on behavior and really what we're doing is we're following the example of Bill Miller who has developed the motivational interviewing approach to to helping people deal with with problematic behaviors including substance use problems but but other behaviors as well so the idea the persuasion stage is we all know that somebody is persuaded that substance use is a problem and wants to work on it when they begin to make a concerted effort to reduce their substance use problems so if we see reductions in substance use or we've seen repeated efforts to reduce substances over a one month period or longer we say they move from the persuasion stage into the active treatment stage so how can you help people become motivated to work on their substance use problems this is actually I I would say both the most frustrating but also potentially the most rewarding of the different stages of treatment and there are many many different strategies one thing I want to mention so I'm only giving examples of strategies your your own creativity is really the only limitation on the types of different strategies that you can use at the different stages as long as you're bearing in mind what the goal is and the goal of course of persuasion is to persuade a person that substance use is a is a problem that they can conquer so one thing is psychiatric stabilization if symptoms are very unique exacerbated it's harder to develop motivation to begin working on substance use problems people often feel demoralized and often their insight is impaired when their symptoms are exacerbated so attempting as as best you can to stabilize symptoms can be important persuasion groups is a group intervention that we've developed up in New Hampshire in which you essentially try to create a safe haven for people to talk about and explore their substance use problems their mental illness problems and the interactions between the two it's a safe place in that nobody's expected to own up to having a problem nobody's confronted with have it with having the Hat with having a problem if people want to talk about the positive aspects of substance use they're allowed to that's fine in fact in many cases consumers are only willing to talk about the negative side of substance use after talking about the positive side and so the idea of a persuasion group is you have people at the persuasion stage but also at later stages talking about their experience and with the expectation that the opportunity to talk and to process the effects of substance use and and poorly controlled mental illness on one's live lives well naturally over time lead to motivation to work on substance use problems family education and an individual education can also play an important persuasion role many consumers don't understand how substances interact with the biological vulnerability that we believe underlies many mental illnesses and so by teaching people about the nature of mental illness about psychiatric diagnosis about the stress vulnerability model which posits that psychiatric illnesses have a biological basis but that biological basis interacts with the environment and that one of the things in the environment that can trigger that biological vulnerability is the use of substances or the use of substances can sometimes compromise the beneficial effects of medication for example by teaching people about stress vulnerability one of the things that we help them understand is that many people with severe mental illnesses have problems using drugs and alcohol not so much because they're using a lot more drugs and alcohol than their peers are but because they're exquisitely sensitive to even the very small amounts of alcohol or cannabis or cocaine that they may be using this is what we call the super sensitivity model by helping consumers understand that they're biologically super sensitive to the effects of alcohol and drugs you open up a door for learning how to manage one's mental illness better in part by decreasing use of substances so psychoeducation could be a power for motivating strategy for individuals I think it's especially important early on in the course of the psychiatric illness often before substance use problems are well ingrained and when and when people are still struggling to come to terms with having a mental illness and how to cope with it there are many other strategies and I really can't go into them and in too much detail here but let me talk about two more strategies just just briefly one about rehabilitation and the second one about motivational interviewing strategies for the persuasion stage rehabilitation of course refers to helping people become more functional more adaptive coping effectively with symptoms getting jobs becoming a better parent being a better parent and then also developing a leisure and recreational activities well how does how does rehabilitation play a role in persuading people with substance use problems to work on their substance abuse well here's how people with dual disorders typically use substances to achieve one of and sometimes more four different kinds of goals sometimes they use substances to cope with symptoms sometimes they use them to facilitate social relationships sometimes they use them just because it feels good you know they're pretty easy to find and and consumers don't have a lot of good feelings going on and so hey you know if you can go and and feel good for for an hour or two I mean that's pretty good even if there is a high price to pay and for some individuals than use of substances in and of itself develops meaning those people who develop a more serious addiction who who use you know large amounts it gives them something to look forward to it structures their lives in certain ways well we can give people better tools forgetting those same types of needs met we can help people cope with symptoms more effectively we can help them develop better and more rewarding relationships with people we can help them get back to work get back to school we can help them develop meaning in their lives as parents as workers and as students in the light to the extent that we do that that we provide rehabilitation at the persuasion stage what we do is we undercut the need and the dependence on using substances to get those same basic needs and desires met so the effective rehabilitation the persuasion stage is indirect by helping people develop better strategies for getting basic needs met which decreases their reliance on using substances to get those same needs man motivational interviewing another strategy very useful at the persuasion stage it's basically a set of strategies designed to take the initial focus off of this destruct off of the destructive behavior and to focus instead on identifying personal values and goals that are important for the individual and after identifying those goals and values to begin the process of breaking them down beginning to take steps towards achieving them and in doing so beginning to explore the extent to which using substances either helps or hinders the ability to achieve goals motivational interviewing is based on the observation that people are most compelled or most desirous of changing behavior when they see it is in their own best interest and the only way really to do that is to first identifying and work towards individuals goals and then to explore whether using substances interferes with with achieving those goals the act of treatment stage I always say by the time you get into the active treatment stage you're almost home-free we define somebody who's moving into active treatment when their substance use has reduced for at least a one-month period of time now they could still be having problems related to substance use or they could have achieved sobriety we say that you stay in active treatment from the time that you've reduced your substance use for at least a month until you have six months of sobriety following six months of sobriety we say you go into the relapse prevention stage so the idea of the active treatment stage is to help people reduce their substance use further hopefully to achieve um abstinence and and sobriety and it's at this stage that many of the strategies developed in the for the population of people with substance use disorders become very applicable with modification to people with dual disorders teaching people to self monitor urges to use cravings actual use can be helpful social skills training for dealing with substance use situations can be helpful now skills training can be used for earlier for example in the persuasion stage when you focus on improving the quality of interpersonal relationships but my feeling is that skills training for dealing with substance use situations or to be held until you have some evidence that the person actually wants to not use in those kinds of situations and that's what active treatment is all about persons would begun to reduce their substance use you assume that they're now motivated to work towards sobriety and so skills training to address substance use situations becomes another effective strategy social network approaches family work in which you do problem-solving the identification of high-risk situations also self-help groups now sometimes people do find helpful to go to a self-help group like dual recovery anonymous or Alcoholics Anonymous or Narcotics Anonymous sometimes those things are helpful at the persuasion stage but they're more appropriate usually at the active treatment stage because there's the assumption when you go to those groups that you have a motivation not to use now it's true that sometimes people in persuasion are thinking about not using they're in that kind of contemplative stage and so it may be helpful to go to self-help groups but it's important as a clinician not to push yourself the self-help um too early and the most appropriate role really is is going to be in the active treatment or the relapse prevention stages where you have good behavioral evidence that the person doesn't want to use substituting activities is another strategy and then developing strategies for dealing with high-risk situations social situations problems in terms of symptom relapses getting paid at work um things like that and addressing motivations and then the relapse prevention stage we define a person's being in will have two prevention when they've got six months or more of sobriety and they're the goals actually become split you want to maintain an awareness that a relapse could happen but then you also want to begin to shift even more and to emphasize even more on other areas of the person's functioning their social relationships their health their their independent living schoolwork the idea being that the more person has going for him or her in their lives the less vulnerable they will be to having a relapse of their substance use there's a lot of different strategies that can be used I'm there so that's the stages of treatment of course the stage is a treatment occur gradually over periods of time and what this figure depicts our stage is over a three year i'm study done in new hampshire study done by a bob drake and colleagues comparing two different approaches to integrated treatment for dual disorders and what you can see is that what we've done is taken the stages concept and broken each stage into two sub stages so for example engagement it's broken into pre i think it's like a pre-engagement what's yeah pre engagement and engagement and then persuasion and active treatment are both early and late persuasion and early and late act of treatment and and then relapse prevention and and then we're calling recovered when a person is is at the very highest level when there's more than a year since they've met a problems related to substance use and what you can see is from this figure it's a little bit complicated but it what you could see is a gradual progression up the stages of treatment over a three-year period and a large sample i think a little bit over 200 individuals with dual disorders now sometimes people say well how long does it really take to get through all the different stages and so and of course it's it's an individual matter but one of the the folks i like to quote a lot is i'm linda fox and the and the late tom fox and what they used to say is well there's there really aren't four different stages of treatment there's really eight different stages and those stages include engagement engage of an engagement followed by persuasion persuasion persuasion which is then followed by active treatment or relapse prevention so indeed there's a lot of time and energy and and some some amount of frustration that happens that that those very early stages may be making the connection with the person and then developing that motivation but as you can see from this study looking at the three-year outcomes and we've continued following up this cohort of people we're up to now 15 years with many of them that you that more and more people over time achieve remission of their substance use problems okay and the stages of treatment we have it as a standardized rating scale behaviorally anchored there's a copy in the book there may be copies on on websites as well well have you've spent some time talking about what integrative treatment is for dual disorders let's spend a few minutes talking about research and then get to some question I'm gonna give you a kind of a selective survey of the research literature we're in the process of updating this survey there are in fact quite a few studies now if you count non controlled studies such as quasi experimental studies and things like that there's over 30 different studies that have been done but I like to focus on the more narrowly on a few of the very rigorously done studies and so I'm just gonna talk for a couple of minutes about six controlled studies and then I'll talk a little bit about directions for future research of the six controlled studies that have been done four of them compared integrated versus non integrated treatment and then two of them compare different approaches to integrated treatment all these studies looked at fully integrated treatment programs that have incorporated many of the core characteristics of integrated treatment that I described earlier these studies by the way are reviewed in in somewhat more detail in the book for people who want more detail on them Godley and colleagues looked at 38 people about half of them with schizophrenia spectrum disorders and they compared intensive case management plus integrated treatment for dual disorders with treatment as usual tau is a very common abbreviation for treatment as usual and they did a two-year follow-up and what they found was that the integrated treatment group had better substance use functioning at the end of the follow-up period and there were no differences in hospitalization and in symptoms in general in integrated treatment studies you don't you don't tend to find major treatment effects on things such as symptoms and hospitalizations although what you do find and I'll show you a slide showing this in a moment is that the people who achieve remission tend to stay out of the hospital and tend to have less severe symptoms than the people who don't achieve remission study done by Bob Drake down in Washington DC on a I think that entirely I'm not sure if it's a hundred percent or like 90 plus percent African American population compared integrated treatment with treatment as usual this was a quasi-experimental a design study which means that they got a group of individuals in one setting and they provide an integrated treatment and then they compared them to a matched group of similar individuals in another setting who continue to get traditional treatment they had a one and a half year follow-up and they found that the integrated treatment program did better than the treatment as usual folks in terms of stages of treatment and the severity of their alcohol problems there were no differences in drug severity hospitalization symptoms and other outcomes then in a study done in several mental health centers in Texas by Carmichael and colleagues they looked at 208 clients 31% with schizophrenia randomly assigned to either integrated treatment or treatment as usual and they found much better outcomes for the integrated group across a range of different areas including alcohol and drug severity adherence to medication arrests income and satisfaction there were no differences in and some of the other clinical outcomes and Christine Berra Clough and Nick terrier and their colleagues what they did was they looked at an integrated treatment program that included a family intervention component and individual psychotherapy component that blended cognitive behavioral therapy for psychosis with motivational interviewing a pretty unique package there and they studied it in 36 individuals with schizophrenia and substance use problems and they compared this integrated treatment program to a treatment as usual program and they did a one-year follow-up and and now there's a longer term follow-up that's recently come out and they found that the integrated treatment group had better outcomes in terms of days abstinence hospitalizations and symptoms and what's interesting about their studies is that their integrated treatment for dual disorders specifically target certain persistence symptoms in addition to working on substance abuse and that might be one of the reasons why they got a main effect on symptom reduction and then that leaves us to a couple of studies looking at different approaches to integrating treatment there was a study by I'm sure Alan and Ridgeley that looked at three different approaches to providing integrated treatment for dual disorders one of them was the social skills they call it a behavioral skills training approach where they taught skills thought to be specifically relevant for dealing with substance use problems that was then compared with an intensive case management approach and that was then compared to a 12-step approach and they got they found pretty good outcomes for everybody but the outcomes were we're best for the skills training group they were intermediate for the intensive case management group and they were least A+ for the group of people who got a kind of adapted 12-step approach and then last study done by Bob Drake have referred to this one earlier that seven different mental health centers in New Hampshire looked at two different approaches to delivering integrated treatment one approach was delivering integrated treatment in an assertive community treatment team and then the other approach was standard case management and what was interesting about this study is that everybody got a package of integrated treatment services so it's really a test of the delivery system rather than of the services themselves they had a three year follow-up and essentially what they found was that the effects of the integrated treatment as delivered in the act model were modestly better than the effects that as they were then the effects of integrated treatment as delivered in a standard case management approach in general people in both of the different services did quite well the overall rates of remission of substance abuse over the 3-year follow-up period or somewhere in the 45% range quite a bit higher than then what surveys indicate one would find in services as usual now from this study one of the things you could see is if you compare the people who achieved remission versus the people who didn't people who achieved remission had more stable housing in the community just what we would expect and similarly people who achieved remission were less likely to be hospitalized this is kind of the mirror it's not the perfect flip image because there's other other ways of not being stable in the community without going into the hospital but just as we expect achieving sobriety is associated with better clinical outcome less severe symptoms less hospitalization and another thing that's interesting about this study because it was done at seven different mental health centers is that what they found is that the the quality of a sort of community treatment with quality defined in terms of fidelity to standard measure of how assertive community treatment is supposed to be delivered was related to outcomes centers that had the highest fidelity tended to have better outcomes in terms of substance abuse over time then centers that had lower fidelity and so what they did was they divided the seven different stud in the seven different sites into high versus low fidelity and you can see that the outcomes of the high fidelity programs as reflected in the blue line there were significantly better over the three years than the outcomes of the people in the low fidelity programs as reflected in the pink lines there are lots of limitations to this research for any doctoral dissertation candidates out there people looking for good areas to do research you don't have to worry about everything already haven't gotten gotten answered in this field oh there are lots of questions in fact people even sometimes have debates is this an evidence-based practice or not you know without coming down on that in one side or another there certainly is mounting evidence that integrated treatment is more effective than non integrated treatment but there's need for much better research among other things that many of the studies that have been done the interventions were not well standardized fidelity that was not routinely assessed in many of the different interventions so far there's no actual replications of effective programs and and replication really being the heart of science that's it's hard at least for me to to be totally confident about something until I've seen it replicated and the control conditions were highly variable and sometimes not well-defined so there's there's lots of good work that needs to be done in this area just to very briefly highlight two areas of of research that we're doing and these are kind of ones that you can kind of keep your eye out on one of them is is looking at a family intervention program that we've developed for people with co-occurring disorders and what we've done is we've developed an intervention program program called family intervention for dual disorders for lack of a catchy er name the FID program we tried and tried to come up with a sexier you know cuter name for it but nobody could agree on it so finally just it's just called the FID program for now and what we do in that is we combine behavioral family therapy specifically focused on helping families learn how to manage co-occurring disorders with multiple family support groups that are done on a monthly basis and sessions can be done either at home or in the in the clinic and the purpose of the behavioral family therapy is to teach basic information and skills about the management of the psychiatric illness and the substance use problems and the purpose of the multiple family groups is to provide support to do group based problem solving and to maintain a long-term connection with the treatment team these are the phases of behavioral family therapy I'm not going to go into that but just so you know behavioral family therapy is a learning oriented intervention designed to teach families and and we always include the consumer in the family of course to teach families about mental illness and the principles of its management to help improve communication skills and teach a structured approach to solving problems that that maximizes collaboration and minimizes tension and these are just the results you don't have to look at them in detail now but these are the results from a pilot study that we did of the behavioral family therapy program and what's depicted here is the stages of treatment that I referred to earlier for each of six different individuals who were in the study and what you could see across all six individuals were improvements in stages of treatment and if you want to know hey what does it really mean remember that each stage is divided into into two sub stages and that going from late persuasion to early active treatment reflects a significant reduction of substance use so when somebody reaches a four in this that's late persuasion that's when they begin substance use reduction when they had a five that sustained substance use reduction so that's one way of looking at that and then this is just another figure from the same study looking at substance use problems using our substance our clinician rating scale and on this clinician rating scale a three four or five refers to a substance abuse substance dependence or severe dependence so what you can see from this is is most of the people actually by the end of two years getting below a three no longer having an active substance use disorder by the end of the the pilot and then last of all who ever heard of antabuse in people with dual disorders in fact doctors are afraid to use disulfiram which has got the the brand name of antabuse because there have been early reports about antabuse exacerbating psychotic symptoms so we did an open trial simply looking at people in the New Hampshire system who had been prescribed antibiotics exacerbates psychotic symptoms how often did it play a critical role in helping people achieve sobriety and so in this study we looked at 33 individuals 70% with schizophrenia or schizoaffective disorder who had treatment refractory alcohol problems and we looked at what the effect of simply prescribing antibiotics on antabuse 28% experienced negative reactions to drinking you might wonder why didn't a higher percentage experienced negative reactions probably because very moderate doses of antibiotics can be pushed to higher levels 500 750 but you know there was an understandable kind of conservativism in the dosage range is that that were used we didn't find any examples of antabuse prescription being associated with an exacerbation of psychosis nor were there any serious medical medically adverse effects associated with drinking when a person was taking interviews so that's kind of the feasibility but look at the outcomes what you could see is that over three years the outcomes were really very good with the majority of people showing significant remission of their alcohol use problems and this is days in the hospital as you might expect drinking reduction in drinking was associated with spending fewer days in the hospital overall 63% had a remission of their alcohol abuse for at least one year 30% had a remission for two years people often showed remissions of drug use as well so I think if this is kind of a promising kind of an interesting study considering how little antabuse is actually used for people who would like to see the full report of this came out last year in the American Journal on the addictions I was the lead author but to me it suggests that that somebody needs to do some controlled research on on this and so to wrap it all up substance use problems were very common in people with severe mental illness and they're associated with a wide range of different negative outcomes precipitation of relapses medical problems family stress economic problems legal problems and the like integrated treatment programs are defined in terms of interventions designed to treat both disorders at the same time by the same clinicians and with a particular focus on the interactions between those an early research on integrated treatment is promising shows that it's associated with better outcomes than traditional segregated parallel or sequential treatment approaches so I don't know how much time we have but I'd be happy to take a few questions in your discussion of phases of treatment the introduction of work or vocational goals I guess came at the very end can you just talk a little bit about that yes it came at the end more well just actually to repeat the question the observation was that in looking at the different stages of treatment our first mention of work really came in the relapse prevention stage and one might quite reasonably wonder well does that mean that we encourage people to put off the search for work until they've achieved sobriety and the short answer to that is no the only reason we brought it up there is to is to talk about an increased focus on those kinds of things but in the same way that helping people develop better relationships with other people helping them become better parents helping them get back to school in the same way that those become motivations for not using substances getting back to work or or keeping a job often what happens is somebody wants to go to work they're still using you know you might be skeptical I mean is they using and interfere with the work but you don't want to you know run the person's life I mean it's the consumers got to make the choice and so it's actually much more effective for the person to go back to work if they begin to experience substances substance uses interfering with the work to use that and to to process that clinically with the consumer with the hope of developing motivation to begin working on the substance use so the answer is that that work in fact is often addressed early on in the course of integrated treatment for dual disorders there's conflicting evidence as to whether having a substance use problem interferes with the ability to get work in supported employment programs several studies indicate that there's no interference whatsoever there's some studies indicating if there is some interference and a study that we recently did in Hartford we did see the people with alcohol use problems had somewhat lower rates of getting jobs about half the people with alcohol use problems got jobs and about eighty I think 83 percent of the people with alcohol problems got jobs so there's something going on there but I mean half the people got jobs so I you know I kind of okay I think it's a very positive kind of a thing so I my belief is that is that work and also the return to school are such important motivational factors that that often they need to come into the duel disorder treatment process earlier rather than later and our belief collectively I mean within the group of people that I you know work with and and and co-authored the book and is strong enough that we have a chapter actually focused just on vocational rehabilitation in the dual disorder book am I was just curious as to whether with and this just from your own personal experience and knowing some of the subjects that you've worked with over the years is there any factor involved with people sort of aging out of use as they mature age wise that you see differences yeah I think that that's a great question to repeat the question is is there any evidence that that there is a natural aging process in substance abuse and what's interesting first is to consider well what do we know about the general population and when you look at the rates of substance use problem and kind of the natural aging process there in fact is a lot of evidence that many individuals naturally aged out of substance use problems in their late 20s and their early 30s and I think one of the reasons why this may not happen as much in people with severe and persistent mental illness is that often there's a kind of a quality of arrested social and role development that occurs when a person develops a mental illness in fact there's there's very interesting research that shows that the that the level of a person's role functioning when they first become ill is relatively predictive of their level of role functioning after they've developed the illness that they don't tend to go a lot higher and that doesn't mean without rehabilitation we couldn't help people get higher but I think what happens in effect is that sometimes people get kind of arrested in a kind of a psycho developmental stage and that and that part of being stuck in that stage is the substance use so we do see over time sometimes people just kind of giving it up you know get getting tired of it but my belief is that the best way to to facility take that process is to attend to royal function he helped them get well first of all developing hope and belief that change is possible really supporting that self-efficacy reframing past experiences as as valuable lessons helping people conceptualize themselves as survivors as as copers and and things like that and then helping them move forward in terms of identifying and pursuing goals and because then that gives you something something to motivate the person around and and and often what happens is that they then experience the substance use interfering with the achieving of that goal and that's how you develop and harness motivation to work on the substance abuse and to me that's that it's it's a way of kind of tweaking that natural developmental process that that often happens and in people who don't have a substance use problem including any alternative therapies in your integrated treatment model like acupuncture for example and my second question is about the 12-step philosophy and principles what role they play in your treatment model good good questions the first is the views of alternative treatments our model is more of a conceptual framework than it is a specific set of programmed in interventions so I think that you could have a program that that included alternative therapies whether they were herbal medicine yoga acupuncture and and things and and that they might really fit an important role in fact in fact I think any program that that helps people deal and cope more effectively with stress and that develops a greater awareness of both oneself and integrated world around them I think those programs are likely to be beneficial to people with with dual disorders we haven't incorporated them I guess partly because we don't have a lot of expertise in that we already got twenty chapters in the book and nobody wanted to write a twenty first chapter but so I don't think it's so much that people don't believe it doesn't work or or are kind of prematurely rejecting it as as much as that it's it's wide open and and so far there hasn't been that that much work in in those areas to my knowledge at least we to focus on certain areas that we knew knew things about and we're either adapting what we were doing from the kind of the psychiatric rehabilitation perspective or or taking interventions from the substance abuse field with respect to the second question which is is well where do the 12-step philosophy what do we think of it first of all we do encourage people especially when they get into active treatment to at least explore self-help options and and by far the most widely available self-help option are the AAA type groups Alcoholics Anonymous or Narcotics Anonymous type groups now there have been modifications of those groups that are more specifically tailored to people who also have a co-occurring psychiatric illness such as dual recovery Anonymous although those are somewhat more difficult to find so we recognize the fact that significant numbers of people with addiction benefit from the basic AAA philosophy the spiritual focus and and things like that at the same time we're also where that significant numbers of individuals with co-occurring disorders seem to be less drawn or find less benefit from those approaches and in our own data those individuals the people with schizophrenia spectrum disorders in fact are less likely to go and to go to those kinds of groups and and report less benefit from them I think for a variety of reasons one is that because the groups are sometimes large there's a there's a heightened level of social anxiety in in those individuals a second thing is that sometimes I think that the spiritual focus of those groups can be confusing to individuals who themselves may have beliefs involving spiritual themes that may be related to their psychiatric illness at the same time turning it around it's probably safe to say that the psychiatric rehabilitation field has ignored or not sufficiently attended to the spiritual needs that people with psychiatric illnesses and and dual disorders have and so connecting people to those groups may in fact help meet some of those needs sometimes kind of the rigid philosophy and some of the abstract concepts that are incorporated in that philosophy can be a little bit difficult to grasp grasp for people with with thinking difficulties so all that put together we look at at 12-step approaches as a valuable approach and and we will sometimes incorporate elements of 12-step approaches but we don't take a kind of a hardcore doctrinaire approach in which we more or less say yeah this is the way I mean our our belief is that many people get better or that people would dual disorders get better following a variety of different paths and and really what's most important is helping each person fine and find and define their own their own pathway and so for some people the twelfth step approach really is a tremendously helpful pathway and one that that's got tons of social support for following but for other people it may be a very different pathway and that and that's fine we're very that's it's very well with us I'll pose the last question which is did you measure readiness for change in the antabuse study and if so what role might that have played in the positive outcomes you saw question is whether we measured readiness for change in the antabuse study and the answer is no not other than getting stages of treatment but we did not use one of the stages of change measures like the Socrates or something like that and and to be honest some of the people in the antabuse study I believe were on conditional discharges from New Hampshire Hospital so and part of the conditional discharge was agreeing to antabuse therapy so there's no doubt that that some coercion was involved in treating some of those individuals I forget the percentage I think it may be as much as a quarter or a third of the those individuals in most cases they're they were individuals who had persistent alcohol problems despite receiving really a quite state-of-the-art integrative treatment for dual disorders including outreach persuasion groups a certain amount of family work think things like that and so what we we find the toughest self or aunt abuse is the professionals not the clients I mean there's certainly clients who say they don't want to use it and the like and you have to respect that but we found in certain settings that that we've worked there professionals who who weren't even put it on the table they won't even consider the use of it because they're concerned either of medical consequences of what happens when a person drinks and that's why I think that the series of 33 people was interesting because we didn't see anybody who had you know any significant medical reactions and concerns about precipitation of psychosis which there were a few case reports very very early primarily in the 70s about antabuse precipitating psychotic symptoms in people who didn't have psychotic disorders but as I described we didn't see that in any of the 33 people that we treated to thank Kim again for this wonderful presentation and thank you all for joining us here at the Center for psychiatric rehabilitation

2 Comments

  1. Motivational interviewing 35mins

  2. Right!!!!?

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