Report to Congress - Nov 2002
REPORT TO CONGRESS ON THE PREVENTION AND TREATMENT OF CO-OCCURRING SUBSTANCE ABUSE DISORDERS AND MENTAL DISORDERS
Interventions both fit within the four quadrant framework described above and help treatment professionals and others ensure that individuals with co-occurring substance abuse disorders and mental disorders receive the most appropriate care. This section is a discussion to help treatment professionals and others ensure that individuals with co-occurring substance abuse disorders and mental disorders receive the most appropriate care. The section includes a discussion of interventions and approaches that have been adopted, adapted and applied for adults with co-occurring disorders.
In addition to specific interventions, researchers are evaluating models of integrated treatment based in typical substance abuse settings including the consultant model (adding a mental health specialist to the team), fully-integrated model (training all staff to address co-occurring disorders), adjunctive psychiatric services within methadone maintenance programs, and the modified therapeutic community (CSAT, in press).
The need for better screening and assessment strategies for people with co-occurring substance abuse disorders and mental disorders was identified by SAMHSA constituents as critical to success at both the program and the system levels. Indeed effective treatment for co-occurring disorders begins with accurate screening and assessment (SAMHSA, 2002f).
High prevalence rates for co-occurring substance abuse disorders and mental disorders, the low treatment rates (Kessler et al., 1996; Regier et al., 1990), and the under-diagnosis of substance use disorders (Drake, et al., 1990), highlight the need for better detection and screening strategies. According to Lehman (1996), the absence of assessment of co-occurring disorders presents the major barrier to effective prevention. Thus a "no wrong door" approach - in which assessment occurs wherever an individual with co-occurring disorder presents him or herself - becomes critical. Moreover, screening and assessment practices serve little value in the creation of a "no wrong door" approach unless they are implemented uniformly across treatment systems to ensure that service systems recognize individuals with co-occurring disorders.
The clinical screening process enables a service provider to assess if an individual with a substance abuse disorder shows signs of a mental disorder, or whether an individual with a mental disorder demonstrates signs of substance abuse. Lehman (1996) has recommended that all programs institute basic screening procedures for substance abuse and mental disorders, regardless of their primary focus. If a problem is identified, providers can initiate a more detailed assessment and an appropriate referral.
A broad range of instruments are available to screen for both disorders (CSAT, in press; Mueser et al., 1995); however, no one instrument is foolproof. Some may miss some cases or incorrectly identify others. Nonetheless, standard screening procedures can help avoid these shortcomings and follow-up assessments can clarify the screening findings.
The importance of appropriate and timely screening for alcohol and drugs of abuse cannot be understated. Drake and colleagues (1996) point out that this failure to detect substance abuse disorders can result in a misdiagnosis of mental disorders, sub-optimal pharmacological treatments, neglect of appropriate substance abuse interventions, and inappropriate treatment planning and referral.
Clearly mental health professionals need a sound education about the epidemiology of co-occurring substance abuse and about appropriate techniques for screening and assessment (Drake et al., 1996). At the same time, substance abuse programs and personnel need the capacity to screen for the full range of mental disorders that may present in clients in treatment in their facilities.
The next step in the diagnostic process for an individual who is suspected to be experiencing co-occurring substance abuse disorders and mental disorders is assessment, which includes evaluation, diagnosis as to severity of illness, and motivation for treatment (Kofoed, 1991). Assessments also should address a broad range of other medical, psychological, and social problems (CSAT, in press; Lehman, 1996). A broad range of assessment instruments have been developed and found effective in both the substance abuse and mental health fields to guide practitioners (CSAT, in press; Carey and Correia, 1998; Mueser et al., 1995; CSAT, 1994; Kofoed, 1991), among them the GAIN assessment (Global Assessment of Individual Needs), a standard assessment for co-occurring disorders for both youth and adults developed as part of a SAMHSA-sponsored project.
While review of specific instruments is beyond the scope of this report, a number of general principles about assessment for co-occurring substance abuse disorders and mental disorders are worthy of mention:
· No single tool represents a "gold standard" for identifying and providing a comprehensive assessment of an individual with co-occurring substance abuse disorders and mental disorders. Rather, assessment is a process with a number of different components; specific tools may be used for different components (CSAT, in press).
· No single correct intervention or program is necessarily appropriate for all with co-occurring disorders. Program placement and treatment interventions must be matched to the needs of each individual (CSAT, in press).
· Accurate diagnosis requires a longitudinal assessment by a skilled clinician with an established trusting relationship with the client (Lehman, 1996).
· Because of the complex nature of co-occurring disorders, it is important to approach the diagnosis as an open-ended process that may change as more information is collected and analyzed (Kofoed, 1991).
· The process of assessment also includes the initial steps of treatment: forming a therapeutic relationship, bringing problems into the open, discussing treatment options, and setting treatment limits, all within the context of ongoing respect and acceptance of the individual (Kofoed, 1991).
Individuals presenting for treatment of co-occurring disorders have unique histories and varying capacities to form treatment relationships; they also are likely to be in different phases of recovery. If the individual is participating in integrated or other co-occurring treatment approaches, the value of staged interventions for individuals with co-occurring substance abuse disorders and mental disorders has been well documented (Drake et al., 1993, 2001; Mueser and Noordsy, 1996; Osher and Kofoed, 1989; Ridgely, Osher & Talbott, 1987). Staged interventions provide a basis for differentiating clients relative to the stability of one of their disorders and the readiness to engage in treatment for the other. Because both severe substance abuse and mental disorders often follow a chronic course with frequent relapses (Osher and Kofoed, 1989), staged interventions provide a valuable structure for clinicians to better match treatment to the needs of individuals. The value of staged interventions for individuals with co-occurring substance abuse disorders and mental disorders has been well-documented (Drake et al., 1993, 2001; Mueser and Noorsdsy, 1996; Osher and Kofoed, 1989; Ridgely, Osher and Talbott, 1987). This stepwise approach to the organization of treatment helps address varying levels of severity and disability of the co-occurring disorders during the course of treatment and recovery.
In the field of mental health, Osher and Kofoed (1989) have suggested four separate stages of readiness for and engagement in substance abuse treatment by an individual receiving care for a mental disorder: engagement, persuasion, active treatment, and relapse prevention. These stages have been used to create an assessment scale to help match level of engagement to the most appropriate treatment interventions (McHugo et al., 1995).
In substance abuse treatment, perhaps the most well known and frequently used conceptual model is the Stages of Change Model by Prochaska and DiClemente (1992). This model describes predictable stages of change for individuals involved in substance abuse, from precontemplation to contemplation, determination, action, maintenance, and relapse prevention. The model has been adapted for use in treatment of co-occurring disorders (CSAT, in press; Ziedonis and Trudeau, 1997).
The helping relationship that is established between client and provider is a critical factor that spans the range of treatment interventions for people with co-occurring disorders. An empathic connection is critical if an effective therapeutic alliance (Minkoff, 2001; Ormont, 1999; Carkuff, 1969). Further substantial evidence supports the role a strong therapeutic alliance plays as a predictor of positive outcomes in psychotherapy (Najavits, 2000; Ziedonis and D'Avanzo, 1998; Luborsky et al., 1985; Carkuff, 1969). Similarly, counselors who demonstrate "empathy, genuineness, respect, and concreteness" also have been shown to have a positive effect on their clients' abstinence from alcohol (Valle, 1981).
The need for positive therapeutic relationships is especially critical for individuals with co-occurring substance abuse disorders and mental disorders in order to get them into treatment and keep them there as needed (Owen et al., 1997). Service fragmentation also places these individuals at high risk for falling through the cracks between multiple treatment systems. The staged approaches to structuring services for this population emphasize the need to engage the person in a trusting relationship and to enhance motivation as a necessary first step to participating in recovery-oriented activities (Miller and Rollnick, 1991; Osher and Kofoed, 1989).
SAMHSA's Substance Abuse Treatment for Persons with Co-Occurring Disorders (CSAT, in press) describes the therapeutic relationship as the lynchpin for successful interventions for people who have co-occurring disorders and identifies elements that can help form that bond. For example, maintain a recovery perspective; manage countertransference 5; monitor psychiatric symptoms; use supportive and empathic counseling; employ culturally appropriate methods; and increase support, organization, and structure.
It is also important to note that therapeutic interactions include individual, group, and family interventions. These approaches are applied as part of traditional treatments for substance abuse and mental disorders, often with some adaptation for frequency and intensity of the interaction (Mueser et al., 1998). By addressing the individual and his/her family as part of the treatment intervention, prevention of the co-occurring disorder may occur where children and others are involved.
One of the significant clinical issues associated with the treatment of people with chronic mental illness is the motivation to adhere to medication regimens. The research literature generally shows that individuals who suffer from both substance use and mental disorders are at particularly significant risk for poor medication adherence (Magura, 2002).
It has been noted that chronic use of drugs of abuse, such as marijuana or cocaine, can produce psychotic symptoms, cause a relapse of existing psychotic illness, or create a need for medication adjustments in order to achieve clinical stability (Hunt, 2002). Individuals with co-occurring substance abuse disorders and mental disorders often need to follow medication regimens as part of their treatment for the mental disorder. Likewise, medications are also used as part of treatment for some substance abuse disorders. A physician prescribes psychiatric medication based on the assessment and diagnosis of the client. The medications also need to be monitored regularly to determine their effect and to help the person manage their own medications appropriately (CSAT, in press).
To help an individual with co-occurring substance abuse disorders and mental disorders to recovery requires an in-depth understanding of the complex interplay of substances of abuse, psychoactive medications, and medications used to treat substance abuse. This complex interplay may affect the therapeutic options available to assist in recovery. An individual actively using alcohol, heroin, cocaine, marijuana, methamphetamine or any substance that can produce alterations of mood, thought or trust creates a unique therapeutic challenge requiring the exercise of great care. An individual recovering from a substance abuse disorder may find cravings enhanced and relapse precipitated by the medication needed to manage the co-occurring mental disorder.
Thus, the introduction and management of medications for individuals with co-occurring disorders often is complex, affected by the stage of recovery and degree of abstinence from substances of abuse, target symptoms, the severity and clarity of the co-occurring mental disorder, poly-substance dependence, motivation to change, and individual and physician preference (Carroll, 1997).
The interactive effects of psychoactive medications and illicit drugs or alcohol, and the effects of prescribed psychoactive medications in people who have substance abuse, require that clinicians take special precautions, as the following examples illustrate:
· An addiction medicine specialist, primary care provider or clinical psychiatrist may need to address the needs of an individual experiencing both depression and cocaine dependence. Selecting an appropriate medication can yield mixed results. Clinical studies have found that desipramine, imipramine, and fluoxetine have produced disappointing results. Either both the depressive symptoms and the cocaine use/craving continued unimproved, or the antidepressant had an effect only on the depression symptoms (Schmitz, 2001). Thus, these and other antidepressants may have only limited effects in individuals with co-occurring depression and cocaine use (Schmitz, 2001).
· Minkoff (2001) notes that benzodiazepines, used to relieve anxiety, are not recommended in the ongoing treatment of individuals with co-occurring substance abuse disorders and mental disorders. Monamine oxidase inhibitors, an antidepressant, are generally contraindicated in individuals drinking alcohol, especially certain wines, or using cocaine. Randall (2001) points out that paroxetine appears to work for the symptoms of social anxiety, but there is insufficient information about the effect on alcohol consumption.
· Caution needs to be exercised in treating alcohol dependent individuals on clozapine, used to treat schizophrenia, with benzodiazepines for alcohol withdrawal; the pharmacodynamic interactions between clozapine and benzodiazepines can produce significant adverse reactions (Devane, 2002).
· A case report detailed the use of cocaine by a individual suffering from schizophrenia and treated with risperidone for 2 years; the individual developed hyperthermia and a movement disorder (Tanvetyanon, 2001).
· Multiple case reports indicate that therapeutic doses of olanzapine taken in conjunction with alcohol may produce dizziness and lightheadedness secondary to orthostatic hypotension (Devane, 2002). This situation is an example of the individual information that should be given to an individual suffering from a co-occurring condition such as schizophrenia and alcohol dependence.
· Methadone is an important medication used in the treatment of people who are dependent on opioids (e.g., heroin). It often is used in individuals with co-occurring disorders. Thus, clinicians need to be aware, for example, that an individual on methadone being treated for depression with desipramine may experience an increase in despiramine levels outside anticipated levels. Alternatively, if that individual is treated with fluoxetine, there may be an increased methadone level beyond the therapeutic range (Devane, 2002).
Thus, clinicians treating co-occurring conditions must have a working knowledge of drug interactions across classes of medications and between therapeutic medications and substances of abuse. They also should be aware that different racial and ethnic groups respond differently to psychiatric medications. Though results vary, a number of recent studies suggest that many Asians, African Americans, and to a lesser extent, Hispanics respond to lower doses of many psychiatric medications, and may have greater side effects even at the lower doses (Wells, 1998).
When it comes to the use of medications for the treatment of substance abuse, addiction medicine specialists have a relatively small armamentarium. Foremost among addiction-related medications is methadone for the treatment of opioid addiction. Since methadone cannot be dispensed outside certain designated methadone treatment programs, opioid dependent individuals with co-occurring severe mental illness should have access to methadone treatment programs that either directly provide mental health services or that have access to off-site mental health service providers who recognize the importance of methadone stabilization. If medication compliance is an issue, an individual on daily dosing at a methadone program might be more successful if both medications were made available at the same place and time.
It is anticipated that buprenorphine will be available for the treatment of opioid abuse and dependence by the end of 2002. At the same time, as a result of changes in the Controlled Substance Act, many office-based physicians will be permitted to prescribe FDA approved schedule 3, 4 or 5 opioid agonists for approved narcotic abuse treatment. Physicians treating anxiety disorders with benzodiazpines need to be aware of the severe drug interaction between benzodiazepines and buprenorphine - sudden death (Reynaud, 1998). SAMHSA plays a role in reviewing and granting waivers of the Controlled Substances Act and the Narcotic Addict Treatment Act to physicians as provided by the Drug Addiction Treatment Act 2000. Only a physician with a SAMHSA waiver can prescribe buprenorphine (once approved by the FDA) or any other schedule 3 to 5 FDA approved medication for the treatment of narcotics addiction.
Previous studies by other investigators have suggested that the antidepressant effects of medication may be important to reverse dsyphoric symptoms and increase motivation for change in dually diagnosed patients. Dr. Edward Nunes, New York State Psychiatric Institute, is currently conducting a NIDA funded study that is developing and evaluating a behavioral therapy for the treatment of depressive disorders among opioid dependent patients (NIDA, 1997b).
Another medication, disulfiram, is a well-established medication used to discourage alcohol consumption. Its use by individuals with co-occurring disorders is controversial, and in the eyes of some clinicians, is actually inappropriate since one side-effect may be the exacerbation of psychiatric symptoms.
The choice of medications for the treatment of substance abuse or co-occurring mental disorders sometimes is influenced by the price rather than the efficacy of the medication. For example, older generic medications may be chosen for individuals with limited means as a result of fiscal demands on treatment programs, cities, States or Tribes. These medications may produce more complications for an individual with chronic mental illness who also actively uses substances of abuse. For example, cocaine use can be responsible for cardiac rhythm problems, made worse, undoubtedly, in individuals taking medications such as thioridazine which cause conduction problems in the heart (Hollister, 1995).
Due to the effects of their disorders, many individuals with co-occurring substance abuse disorders and mental disorders are not ready or able to benefit from abstinence-oriented programs (Ziedonis and Trudeau, 1997; Test et al., 1989). Many also lack the motivation to engage in treatment regimens to manage psychiatric symptoms or to work toward functional goals such as housing or employment (Drake, Essock et al., 2001).
Motivational interventions emerged in the substance abuse field (Miller and Rollnick, 1991) but have been adapted as part of intervention models for people with severe mental illnesses and co-occurring substance abuse (Drake et al., 1998; Mueser and Noordsy, 1996; Ridgely and Jerrell, 1996). These approaches have been used to help individuals become ready to participate in treatment that includes illness self-management (Mercer-McFadden, 1997; Cary, 1996).
Research in the substance abuse field has demonstrated that motivational enhancement techniques are associated with greater participation in substance abuse treatment and positive treatment outcomes. Such outcomes include reductions in consumption, increased abstinence rates, social adjustment, and successful referrals to treatment (Landry, 1996; Miller et al., 1995). A positive attitude and commitment to change are associated with positive treatment outcomes (Miller and Tonigan, 1996; Prochaska and DiClemente, 1992).
Motivational enhancement techniques must be matched to the client's stage of recovery and are often integrated as part of the Transtheoretical Stages of Change Model (Prochaska and DiClemente, 1992). Interventions include a range of clinical strategies designed to enhance motivation for change, including counseling, assessment, multiple sessions, or brief interventions. Five key principles of motivational enhancement include: express empathy; note discrepancy between current and desired behavior; avoid argumentation; refrain from directly confronting resistance; and encourage self-efficacy, or the individual's belief that he/she has the ability to change (Swanson et al., 1999, in CSAT, in press).
This approach has been successful with a variety of problems, client populations, and settings, and the methodology appears to be generally applicable, although it was developed primarily with heavy drinkers and cigarette smokers. It can be useful to help instill motivation throughout all phases of recovery and treatment with culturally and economically diverse populations (CSAT, 1999c). Motivational interventions are relatively new but represent a promising approach to facilitating positive behavior change for people with co-occurring substance abuse disorders and mental disorders.
Cognitive-Behavioral Therapy (CBT) uses cognitive and/or behavioral strategies to identify and replace an individual's irrational beliefs that arise from substance abuse or mental illness (e.g., "The only time I feel comfortable is when I'm high.") with rational beliefs (e.g., "It's hard to learn to be comfortable socially without doing drugs but people do so all the time.") (CSAT, 1999b). CBT approaches have been applied in both the substance abuse and mental health fields, especially as part of relapse prevention programs (Beck et al., 1993). CBT can be conducted as part of individual and group interventions.
CBT has been adapted for individuals with co-occurring substance abuse disorders and mental disorders. For example, Weiss and colleagues (1998) developed a 20-session relapse prevention group for people with co-occurring bi-polar and substance abuse that includes a treatment manual describing the model. Two group therapists, trained in both substance abuse and mental health, use non-confrontational methods to help group participants with ambivalence about complying with treatment, coping with high-risk situations, self-monitoring of moods and thought patterns that trigger drug use, and with life-style modifications that promote better self-care and positive interpersonal relationships. An outcome evaluation of this model will be implemented as part of the National Institute of Drug Abuse's Behavioral Therapies Development Program. The primary goals for this program include:
· Provide education about the nature and treatment of substance abuse and mental disorders.
· Help clients come to terms with their illnesses.
· Encourage clients to offer and receive support from each other as part of their recovery efforts.
· Help clients develop the desire for abstinence, and then attain it.
· Ensure compliance with treatment plans, especially medications.
NIDA's Behavioral Therapies Development Program delineates three stages of behavioral therapy research. Stage 1, the earliest stage of behavioral therapy development research, is viewed as an iterative process involving identifying promising clinical, behavioral, and cognitive science relevant to treatment, generating new behavioral therapies, operationally defining the therapies in manuals, and pilot testing and refining the therapies. Stage II research consists of efficacy testing of promising therapies and investigation of the mechanisms and key components of behavioral therapies. Stage III research is aimed at understanding if and how an efficacious therapy may be transported to the community, including testing the utility of training procedures and techniques. NIDA's Behavioral Treatment Development program includes the development and testing of behavioral therapies, alone and in combination with pharmacotherapies, for individuals with co-occurring substance abuse disorders and mental disorders.
Another model program that utilizes cognitive-behavioral approaches with this population has been tested by Kavanaugh and colleagues (1998), and three research groups are refining cognitive-behavioral approaches in substance abuse counseling to better serve individuals with co-occurring mental disorders (Barrowclough et al., 2000; Bellack and DiClemente, 1999; Graham, 1998; Carey, 1996).
The Therapeutic Community (TC) has been addressing the needs of people with substance abuse disorders for more than 30 years and its methods and effectiveness have been well-documented (DeLeon, 2000; Lees el al., 1999; Hubbard et al., 1997; Roberts, 1997; DeLeon, 1993). The concept is based on a clearly defined theoretical model that views drug abuse as a disorder of the entire individual necessitating a focus on conduct, attitudes, moods, values, and emotional management. The approach focuses on creating structures and activities within residential environments to promote personal integration and recovery.
Modified Therapeutic Communities (MTCs) adapt the principles and methods of the TC to the needs of individuals with co-occurring disorders. As with TCs, MTCs promote a culture in which individuals can learn from each other and grow from being a part of a community. Four general areas define the types of interventions provided:
· Community enhancement (to promote affiliation within the community)
· Therapeutic/educative activities (to promote expression and instruction)
· Community/clinical management (to maintain a safe environment)
· Vocational activities (to operate community facilities and prepare for employment)
The key modifications from the formal TC model include increased flexibility, decreased intensity, and greater individualization for people with co-occurring disorders. Activities are adapted in response to the individual's co-occurring disorder, cognitive impairments, and levels of functioning (Sacks, 2000).
The MTC has been implemented not only in community residential programs (Sacks et al., 1998), but also in general hospitals (Galanter et al., 1993), substance abuse treatment programs (Argus community, 1998), and as part of traditional, long-standing TC agencies such as Phoenix House, Walden House, and Gaudenzia, Inc. (Guydish et al., 1994; Sacks et al., 1998). Evaluations of the MTC approach have demonstrated positive outcomes for drug use and employment (DeLeon, 2000), psychological functioning (Rahav et al., 1995), and involvement in criminal activity (Sacks et al., 2001).
Assertive Community Treatment (ACT) is an outpatient treatment model, adapted from traditional case management methods, for individuals with serious mental illnesses. Designed to provide more intensive, long-term services for individuals requiring assertive outreach and engagement due to their reluctance to engage in traditional treatment approaches (Stein and Test, 1980). ACT's core components include community-based services; assertive engagement with active outreach; high intensity services; small caseloads; continuous 24-hour responsibility; team approach (full team takes responsibility for all clients on the caseload); multi-disciplinary team, reflecting integration of services; close work with other community support systems; and continuity of staffing (Drake et al., 1998).
These programs place a special focus on engaging the person in a positive helping relationship, providing assistance with basic needs such as housing, supporting stable functioning in the community, and providing direct and integrated mental health and substance abuse services. The approach also has been applied with homeless and criminal justice populations.
By adding a substance abuse treatment component, ACT has been modified to address the needs of individuals with co-occurring disorders, particularly those with serious and persistent mental illnesses who have had difficulty engaging in traditional approaches. In addition to the core components of the basic ACT program, a number of specialty activities have been added (Stein and Santos, 1998; Drake, McHugo et al., 1998; Ridgely and Jerrell, 1996).
· Direct substance abuse treatment interventions (often through the inclusion of a substance abuse counselor on the multidisciplinary team).
· A team focus on clients with co-occurring disorders (Drake, McHugo et al., 1998).
· Treatment groups for individuals with co-occurring disorders (Drake, McHugo et al., 1998).
· Modifications of traditional mental health interventions, including a strong focus on the interrelationships between substance abuse and mental health issues (e.g., skills training that addresses social situations involving substance abuse) (Drake and Mueser, 2000).
Growing evidence supports the therapeutic effectiveness of the ACT model for individuals with co-occurring disorders, particularly when both the substance abuse and mental health treatment related services were provided directly by the ACT team (Drake and Mueser, 2000; Drake, McHugo et al., 1998). In fact, little evidence supports the success of ACT in reducing substance abuse when the substance abuse services were brokered to other providers and not provided directly by the ACT team (Morse et al., 1997).
Two recent studies have demonstrated a measure of cost-effectiveness for the ACT approach (McHugo et al., 1998; Drake et al., 1996, Drake, Jerrell et al., 1996; Jerrell et al., 1994), even though the overall costs to implement ACT fully for any single client can be high (CSAT, in press). Nonetheless, based on the evidence collected to date and the accessibility and clinical utility of its methods, ACT has been recommended by clinical experts as an exemplary treatment model to help meet the needs of individuals with co-occurring substance abuse disorders and mental disorders (CSAT, in press).
People with co-occurring substance abuse disorders and mental disorders frequently have multiple health, mental health, substance abuse, and social service needs, such as housing and employment. For this reason, treatment providers must be prepared to help clients access a broad array of services to stabilize their living conditions and sustain their recovery. When each of the needs - health, habilitation, housing, and vocation - are met, outcomes for people with co-occurring substance abuse disorders and mental disorders improve.
For example, McLellan and colleagues (1998, 1993) found that clients with substance abuse who also received mental health, vocational, medical, legal, and family services evidenced improved outcomes. Two areas of particular value are housing and work (CSAT, in press). See the discussion of homelessness in the next section of this chapter for more information about housing.
Employment can be an important part of the recovery process, helping people with co-occurring disorders develop the motivation to change, stabilize their psychiatric symptoms, and attain sobriety (Shaheen et al., 2000; Blankertz et al., 1998, in CSAT, in press). Successful job training programs for people with co-occurring disorders include comprehensive assessment, ongoing case management, housing, supportive services, job training and job placement services, and follow-up. Work and vocational rehabilitation have long been part of the services offered to individuals recovering from mental illnesses, and to a lesser degree from, in part because in the past, clients often were expected to first maintain a period of sobriety.
In spite of the special challenges they face, many people with co-occurring disorders do work. Effective employment program models for people with serious mental illnesses and co-occurring substance abuse - including programs of transitional employment, supported employment, and individual placement and support - must be flexible in how they define success and be prepared to work with individuals over the long-term. A "work-first approach," as opposed to extensive pre-vocational training, can motivate a person to address other problems in his or her life including substance abuse (Shaheen et al., 2001).
In addition to involvement in self-help groups, it is critical for consumers and recovering persons and their family members to play a role in every aspect of the development and implementation of both substance abuse and mental health programming (U.S. DHHS, 1999b). The need to enhance consumer participation was also highlighted by SAMHSA constituents (SAMHSA, 2002f).
Consumers and recovering persons may well be their own best advocates, and today, many are engaged actively in the substance abuse treatment and mental health services fields. They bring special characteristics that support the recovery of individuals from both substance abuse and mental disorders: subjective knowledge of the service delivery system, empathy for the struggles related to the process of recovery, a capacity to build rapport, and fundamental respect for the integrity of each person.
Consumers and recovering persons have also become advocates in the communities where they live and work, and have been involved in initiatives to shape policy at the Federal, State, and local levels. In therapeutic communities and modified therapeutic communities (described above), consumers are an integral part of every feature of programming (Sacks et al., 1998).
In addition, consumers and recovering persons have become active participants in the self-help movements in both substance abuse and mental health fields by developing consumer-run programs from drop-in centers with case-management and recovery support components, to outreach programs, and from housing programs to crisis services. Consumers and recovering persons are also often employed as staff in programs operated by non-consumer professionals (U.S. DHHS, 1999b).
Critically, consumer involvement has provided an effective means to deal with the discrimination and stigma associated with substance abuse and mental disorders. Stigma leads many people to avoid living, socializing, or working with, renting to, or employing people with these disorders (Levey et al., 1995). Stigma also reduces consumer access to resources and opportunities, fuels isolation and hopelessness, and leads to outright discrimination and abuse (U.S. DHHS, 1999b). By becoming directly involved in all aspects of their care, consumers have had increasing success in making change happen. They have helped shape policies and programs that are non-discriminatory, advocated for change at the community level, and supported each other in dealing with the negative consequences of discrimination and stigma.
Within the substance abuse treatment community there is a recognition that professional treatment has natural limits and that continuing care beyond formal professional treatment is critical to achieving a satisfactory outcome for individuals affected by substance use disorders. One important and inexpensive form of continuing care is the self-help, peer support or mutual aid program.
Self-help programs are a central feature of most substance abuse treatment programs. More recently, they also have become an important source of support for individuals with mental disorders. During the past decade, recovery/self-help programs specifically for people with co-occurring substance abuse disorders and mental disorders have also emerged as an important adjunct to treatment (Pepper and Ryglewicz, 1996; Dupont, 1994).
Self-help approaches have their genesis in programs like Alcoholics Anonymous and have grown to address a wide variety of addictions. Narcotics Anonymous and Cocaine Anonymous are two of the largest self-help organizations in the area of chemical addictions (CSAT, in press). Recovery Anonymous and Schizophrenics Anonymous support individuals living with mental disorders (Chamberlain and Rogers, 1990).
Self-help programs usually include the "12-step method," with its focus on developing personal responsibility within the context of peer support. Specific applications, however, may vary based on the needs and orientation of agencies/communities sponsoring the programs. Four key factors have given rise to the creation of recovery/self-help programs specific to the needs of individuals with co-occurring disorders:
· Stigma and Prejudice. Stigma related to both substance abuse and mental illnesses can create significant barriers to establishing trust and safety in traditional self-help groups.
· Inappropriate Advice (Confused Bias). Some members of self-help and mutual-help groups do not support the use of medications to treat the symptoms of mental illnesses. In some situations, people with co-occurring disorders have felt the need to stop taking medications to benefit from the groups. The Alcoholics Anonymous (AA) mutual-help groups have helped address this issue in a brochure, "The AA Member: Medications and Other Drugs" (1984) that supports the appropriate use of medications for co-occurring disorders.
· Direction for Recovery. Traditional self-help programs provide support and direction based on years of collective peer experience. Dual recovery programs for people with co-occurring substance abuse disorders and mental disorders provide the opportunity to draw upon collective peer experience with both disorders.
· Acceptance. Traditional self-help programs create environments supporting the experience of safety and security that are central to recovery. Dual recovery programs provide participants with the opportunity to share openly and honestly about their experiences with both disorders (Hamilton, 2001).
Laudet (2000) conducted a survey of about 300 members of Double Trouble in Recovery, a 12-Step oriented self-help group. Three areas of members' difficulty were: (1) dealing with feelings and inner conflicts, (2) work and money problems, and (3) maintaining sobriety. Magura (2002) found that consistent participation in Double Trouble in Recovery was associated with better medication adherence. Individuals who were less adherent to their medication regimen had more severe symptoms of mental disorders at the one-year follow-up point.
Despite the apparent problems that occur for people recovering from co-occurring disorders in traditional 12-Step programs, Laudet (2000) reported that a majority of those attending co-occurring self-help groups also attended either Alcoholics Anonymous or Narcotics Anonymous to focus on their substance use issues or to stay clean.
5 Countertransference refers to an often unconscious transference of the clinician's emotional needs and feelings to the client.