TIP 9: Coexisting Conditions

Chapter 8 -- Psychotic Disorders

Dual-Focus Perspective

This chapter is an overview of current assessment and treatment principles for patients with alcohol and other drug (AOD) use disorders and psychosis. Along with an increased awareness of the treatment needs of patients with these dual disorders, an increased emphasis on service systems has evolved. These and other forces have prompted the need to reassess traditional models and service approaches to develop assessment and treatment strategies that meet the specific needs of patients with AOD use disorders and psychosis.

All too often, AOD use disorders are undetected in patients with psychotic disorders, and traditional treatment approaches are often inadequate. For example, attempts have been made to treat psychotic and AOD use disorders in a sequential manner, treating one disorder first and then the other. While a single-focus approach is helpful for differential diagnosis, and is effective in treating some patients, it is frequently unsuccessful for patients with AOD problems who have severe and recurrent psychotic episodes. This chapter provides an overview of a dual-focus approach to the assessment and treatment of patients with these dual disorders. A single-focus approach emphasizes the importance of developing a diagnosis and subsequent treatment plan -- such as is done when treating patients who have a single disorder. In a dual-focus approach, the emphasis is not on making a diagnosis, but rather on 1) the severity of presenting symptoms, 2) crisis intervention and crisis management, 3) stabilization, and 4) diagnostic efforts within the context of multiple-contact, longitudinal treatment. By concentrating on symptoms, crisis management, and stabilization, clinicians can simultaneously focus on patients' treatment needs that are caused by both the psychotic and AOD use disorders, rather than focusing on one disorder or the other.

Dual-Focus Approach for Assessing and Treating Patients with Dual Disorders

Definitions and Diagnoses

The term psychosis describes a disintegration of the thinking process, involving the inability to distinguish external reality from internal fantasy. The characteristic deficit in psychosis is the inability to differentiate between information that originates from the external world and information that originates from the inner world of the mind (such as distortions of normal thinking processes) or the brain (such as abnormal sensations and hallucinations).

Psychosis is a common feature of schizophrenia. Psychotic symptoms are often a feature of organic mental disorders, mood disorders, schizophreniform disorder, schizoaffective disorder, delusional (paranoid) disorder, brief reactive psychosis, induced psychotic disorder, and atypical psychosis.

Schizophrenia is best understood as a group of disorders with similar clinical profiles, invariably including thought disturbances in a clear sensorium and often with characteristic symptoms such as hallucinations, delusions, bizarre behavior, and deterioration in the general level of functioning.

Severe disturbances occur with relation to language and communication, content of thought, perceptions, affect, sense of self, volition, relationship to the external world, and motor behavior. Symptoms may include bizarre delusions, prominent hallucinations, incoherence, flat affect, avolition, and anhedonia. Functioning is impaired in interpersonal, academic, or occupational relations and self-care.

Schizophrenia can be divided into subtypes: 1) in the paranoid type, delusions or hallucinations predominate; 2) in the disorganized type, speech and behavior problems predominate; 3) in the catatonic type, catalepsy or stupor, extreme agitation, extreme negativism or mutism, peculiarities of voluntary movement or stereotyped movements predominate; 4) in the undifferentiated type, no single clinical presentation predominates; and 5) in the residual type, prominent psychotic symptoms no longer predominate. The diagnosis of schizophrenia requires a minimum of 6 months' duration of symptoms, with active psychotic symptoms for 1 week (unless successfully treated).

Clinicians generally divide the symptoms of schizophrenia into two types: positive and negative symptoms. Acute course schizophrenia is characterized by positive symptoms, such as hallucinations, delusions, excitement, and disorganized speech; motor manifestations such as agitated behavior or catatonia; relatively minor thought disturbances; and a positive response to neuroleptic medication.

Chronic course schizophrenia is characterized by negative symptoms, such as anhedonia, apathy, flat affect, social isolation, and socially deviant behavior; conspicuous thought disturbances; evidence of cerebral atrophy; and generally poor response to neuroleptics. In general, acute substance-induced psychotic symptoms tend to be positive symptoms. .

Schizophreniform disorder is a condition exhibiting the same symptoms of schizophrenia but marked by a sudden onset with resolution in 2 weeks to 6 months. Some patients exhibit a single psychotic episode only; others may have repeated episodes separated by varying durations of time.

Schizoaffective disorder is a condition that includes persistent delusions, auditory hallucinations, or formal thought disorder consistent with the acute phase of schizophrenia, but the condition is also frequently accompanied by prominent manic or depressive symptoms. Schizoaffective disorder is further divided into bipolar (history of mania) and unipolar (depression only) types. .

Delusional disorders are characterized by prominent well-organized delusions and by the relative absence of hallucinations; disorganized thought and behavior; and abnormal affect. The delusional disorders are divided into six types: persecutory, grandiose, erotomanic, jealous, somatic, and unspecified.

Brief reactive psychosis describes a condition in which an individual develops psychotic symptoms after being confronted by overwhelming stress. The onset of symptoms is abrupt, without the gradual symptom development often seen in schizophrenia or schizophreniform disorder, and the duration is brief (no longer than 1 month). .

Induced psychotic disorder describes a disorder characterized by the uncritical acceptance by one person of the delusional beliefs of another. In other words, a dominant partner has a delusional psychosis that is believed and accepted by a passive partner.

Substance-Induced Disorders

AOD-induced psychotic disorders are conditions characterized by prominent delusions or hallucinations that develop during or following psychoactive drug use and cause significant distress or impairment in social or occupational functioning. This disorder does not include hallucinations caused by hallucinogens in the context of intact reality testing.

Although there can be great variability in individual susceptibility to AOD-induced psychotic symptoms, it is important for the clinician to determine if the presenting symptoms could plausibly be induced by the type and amount of drug apparently consumed. For example, vivid auditory, visual, and tactile hallucinations are plausible side effects of a 5-day, high-dose cocaine binge. However, should these symptoms emerge during a brief episode of mild alcohol intoxication, it is likely that the symptoms represent an underlying psychotic process that has been exacerbated by the use of alcohol.

Stimulant-Induced Symptoms

Psychotic symptoms induced by stimulant intoxication are unusual when stimulants are used in low doses and for brief periods. Acute stimulant intoxication in the context of a chronic, high-dose pattern can cause symptoms of psychosis, especially if coupled with a lack of sleep and food and environmental stressors. Stimulant-induced psychotic symptoms can mimic a variety of psychotic symptoms and disorders including delirium, delusions (often persecutory and paranoid), prominent hallucinations, incoherence, and loosening of associations. Stimulant delirium often includes formication, a tactile hallucination of bugs crawling on or under the skin.

Depressant-Induced Symptoms

Particularly when unmedicated, sedative-hypnotic withdrawal can include symptoms of psychosis. Acute withdrawal from alcohol, barbiturates, and the benzodiazepines can produce a withdrawal delirium, especially if use was heavy and tolerance was high or if the patient has a concomitant physical illness. Hallucinations and delusions are common features of sedative-hypnotic withdrawal delirium.

Psychedelic- and Hallucinogen-Induced Symptoms

Many psychedelic drugs, such as the amphetamine-related psychedelics (for example, MDMA and MDA), are not hallucinogenic at the lower doses associated with situational psychedelic drug use. However, in a chronic, high-dose pattern of use (which is rare), psychotic symptoms are possible, by virtue of the drugs' stimulant properties. Other psychedelic drugs, such as LSD, have strong hallucinogenic properties.

Hallucinogen intoxication can cause hallucinogenic hallucinosis, characterized by perceptual distortions, maladaptive behavioral changes, and impaired judgment. Hallucinogen intoxication may also prompt hallucinogenic delusional disorder and a hallucinogenic mood disorder. However, hallucinogen-induced perceptual distortions such as hallucinations or visions are not considered evidence of psychosis when the drug user retains reality testing and is aware that the distortions are drug induced. Acute marijuana intoxication can produce a delusional disorder that may include persecutory delusions, depersonalization, and emotional lability. Similarly, acute PCP intoxication can lead to delirium, delusions, or a PCP-induced mood disorder.

Prevalence

Various studies have noted that the lifetime prevalence rate for schizophrenia is roughly 1 percent among the general population (Africa and Schwartz, 1992). In the Epidemiologic Catchment Area (ECA) studies, the prevalence rate for schizophrenia and schizophreniform disorders combined were as follows: 1) 1-month prevalence rate: 0.7 percent; 2) 6-month prevalence rate: 0.9 percent; and 3) lifetime prevalence rate: 1.5 percent (Regier et al., 1988).

The ECA studies reported that the lifetime prevalence rate of schizophrenia was 1.5 percent, and the 6-month prevalence rate was 0. 8 percent. The lifetime and 6-month prevalence rates of schizophreniform disorder were both 0.1 percent (Regier et al., 1990).

Clinical observation of high rates of AOD use disorders among patients with schizophrenia were supported by the ECA studies. Among individuals identified as having a lifetime diagnosis of schizophrenia or schizophreniform disorder, 47 percent have met criteria for some form of an AOD use disorder. Indeed, the odds of having an AOD use disorder are 4.6 times greater for people with schizophrenia than the odds are for the rest of the population: the odds for alcohol use disorders are over three times higher, and the odds for other drug use disorders are six times higher (Regier et al., 1990).

One study noted that among patients with AOD use disorders, 7.4 percent had a lifetime diagnosis of schizophrenia; the 1-month prevalence rate was 4.0 percent (Ross et al., 1988), although other studies of persons in AOD abuse treatment found the prevalence of schizophrenia to be about the same as in the general population -- about 1 percent (Rounsaville et al., 1991). While patients with AOD use disorders may experience acute episodic psychotic symptoms, few meet the diagnostic criteria for schizophrenia if AOD-induced symptoms are excluded.

Among severely mentally ill outpatient treatment populations, AOD use disorders are common; often more than 50 percent have AOD use disorders, depending upon the treatment setting. Among patients being treated for psychiatric problems in acute settings such as inpatient hospitals, combined psychiatric and AOD use disorders are also common.

Among patients with combined psychotic and AOD use disorders, bizarre behavior and communication generally prompt a mental health referral. Thus, people with psychotic disorders usually receive services through the mental health system and are rarely treated in the typical addiction treatment program.

Lifetime Prevalence Rates

Case Examples

The following three case examples can help to demonstrate the need for a dual-focus approach to treating patients with combined psychotic and AOD use disorders, or patients with psychotic symptoms and AOD use disorders.

Martha

Married for over 15 years, Martha was responsible for most of the duties related to raising four children and maintaining the home. In the past, she had been treated for an episode of postpartum psychosis. Until recently, she had not required any psychiatric medications or mental health services.

Her husband, a successful businessman, was the family's only source of financial support and was emotionally distant. While Martha believed that her husband was frequently out of town on business trips, he was actually nearby having an affair with a woman whom Martha had known for many years. One day, he abruptly informed Martha of the affair and moved out of the house.

During the next 3 days, Martha was intensely depressed and agitated. Her normally infrequent and low-dose alcohol use escalated as she attempted to diminish her agitation and insomnia. During this time, she ate and slept very little. She began to feel extremely guilty for even the smallest problem experienced by her four children. She felt burdened by what she called her "transgressions, faults, and sins." She expressed fears about being doomed to "eternal damnation." Loudly and inconsolably, she declared that she "had lost her soul" and would have to repent for the rest of her life. While being taken to a nearby clinic for evaluation, she passionately described a conspiracy by members of the Catholic Church to steal her soul.

Thomas

In his inner-city neighborhood, Thomas is well known by the local medical clinic, AOD treatment program, and community mental health program. During the day, he spends much of his time walking around the neighborhood, frequently talking to himself or arguing with an unseen individual. He spends most of his evenings in the park in a wooded area away from other people, except in the winter when he sleeps in community-run shelters.

Thomas has a prominent scar in the center of his forehead. When asked about it, he describes in great detail his "third eye," and the fact that he can see into the future through the eye. When asked about his stated reluctance to live in an apartment, he describes an aversion to "electromagnetic fields" that drain his "life force" and make it difficult for him to "think about good things." For extended periods lasting several months, Thomas appears disheveled and agitated, and can be seen drinking heavily or using whatever drugs are available.

However, he also experiences prolonged periods during which he does not drink or use other drugs, appears well groomed, and exhibits less severe psychotic behavior. In general, Thomas is pleasant and well liked, although he is known to become hostile and potentially violent during periods when he uses AODs.

Laura

During a rock concert, Laura was brought by her boyfriend Morris to the paramedics at a first aid station in a large auditorium. Morris described Laura's gradual deterioration over a 1-hour period. At first, Laura displayed abrupt shifts in affect, giddy and laughing one moment and agitated and impulsive the next. Morris said that she began "talking crazy" and not making much sense. He also mentioned that Laura had brief bursts of absolute terror lasting a few seconds or minutes, during which he had to stop her from running away. Morris believed that she was responding to hallucinations. He said that Laura stopped speaking and appeared to have lost the ability to do so. Later, she had a hard time walking and tried to crawl away from Morris. By the time that the paramedics were able to examine her, Laura was rigid, immobile, mute, and unable to communicate with others. Later, Morris admitted that they had used some PCP.

Case Example Discussion

As can be seen, Martha, Thomas, and Laura have very different long-term needs. Martha's brief reactive psychosis and depression may never recur, and the relationship between her alcohol use and psychiatric symptoms should be explored. Thomas's chronic psychosis and frequent AOD abuse episodes are intricately woven together and require combined treatment. Until Laura's boyfriend provided information about Laura's acute drug use, the reason for her psychotic episode was unclear.

These case examples are valuable to demonstrate how the absence of a dual-focus approach can lead to treatment failure. While Martha's psychotic episode was related to overwhelming stress, her alcohol use might be underemphasized in a traditional mental health setting. Doing so may obscure the possibility that her drinking severely deepened her depression, increased daytime agitation, and exacerbated the psychotic episode.

While Thomas has an ongoing psychosis and AOD abuse problems, focusing on only one set of these problems means that he bounces back and forth between the mental health and addiction treatment programs, depending upon his current symptoms. His involvement with the local medical clinic for treatment of physical injuries that are sustained during episodes of impaired thinking often complicates his already uncoordinated treatment.

While Laura's drug-induced psychosis may fade as the drug is eliminated from her body, the episode can be used as a point of entry into AOD abuse treatment. Also, her immediate needs will be the same irrespective of the cause of her psychotic episode.

As these case examples illustrate, patients who experience psychosis and AOD use problems are often highly symptomatic and may have multiple psychosocial and behavioral problems. It is common for patients with dual disorders to have undergone different approaches to treatment by different providers without long-term success. Furthermore, clarifying the diagnosis and "underlying disorder" is extremely complicated in the early phases of assessment. The first step in treatment of a person with a dual disorder is an assessment that addresses biological, psychological, and social issues.

Acute Assessment

A common difficulty that clinicians experience is determining whether psychotic symptoms represent a primary psychiatric disorder or are secondary to AOD use. However, in the early phase of assessment, the goal is to stabilize the crisis rather than to establish a final diagnosis. The final diagnosis is often best determined during a multiple-contact, longitudinal assessment process. All assessments include direct client interviews, collateral data, client observations, and a review of available documented history.

Assessment of High-Risk Conditions

The initial step of every assessment is to determine whether the individual has an imminent life-threatening condition. There are three domains of high risk that require assessment: biological (or medical), psychological, and social. At any given time, one aspect of this biopsychosocial approach may be more urgent than the others.

Medical Risks

With regard to medical or biological issues, the goal of assessment is to ensure that patients do not have life-threatening disorders such as AOD-induced toxic states or withdrawal, delirium tremens, or delirium. Also, patients may be exhibiting symptoms that represent an exacerbation of their underlying chronic mental illness. The symptoms may be due to an aggravation of medical problems such as neurological disorders (for example, brain hemorrhage, seizure disorder), infections (central nervous system infection, pneumonia, AIDS-related complications), and endocrine disorders (diabetes, hyperthyroidism). The presence of cognitive impairment (such as acute confusion, disorientation, or memory impairment), unusual hallucinations (such as visual, olfactory, or tactile), or signs of physical illness (such as fever, marked weight loss, or slurred speech) show a high risk for an acute medical illness. Patients who exhibit this degree of risk need to be immediately referred for a comprehensive medical assessment.

Psychological Risks

With regard to psychological issues, the primary goal must be an assessment of danger to self or others and other manifestations of violent or impulsive behavior. Patients with a dual disorder involving psychosis have a higher risk for self-destructive and violent behaviors. Patients should be assessed for plans, intents, and means of carrying out dangerous behaviors. Patients who are imminently suicidal, homicidal, or dangerous need to be in a secure setting for further assessment and treatment. In addition, some patients may have cognitive impairment related to their dual disorder and be unable to adequately care for basic needs.

Social Risks

With regard to social issues, the primary goal is to ensure that patients have access to minimal life supports and have their basic needs met. Patients with a dual disorder involving psychosis are particularly vulnerable to homelessness, housing instability, victimization, poor nutrition, and inadequate financial resources. Patients who lack basic supports may require aggressive crisis intervention, such as the provision of food and assistance with locating a safe shelter. Lack of these social supports can be life threatening and can worsen medical and psychiatric emergencies.

Biopsychosocial Assessment of High-Risk Conditions

High-Risk Probing Questions

To provide a thorough assessment of patients who are experiencing psychotic symptoms, it is important to directly question patients about the three domains of medical, psychological, and social safety.

Medical Safety

In the absence of overwhelming medical and psychiatric crises, the clinician should ask patients a series of questions that relate to medical assessment. One example is: "Have you been diagnosed or hospitalized for any major medical disorders?" Similar questions should address the recent onset of significant medical symptoms, episodes of head trauma or loss of consciousness, prescribed and over-the-counter medications, recent changes in medications, the use of AODs, and nutritional and sleep needs.

In addition, the assessment of medical symptoms should include a thorough cognitive examination of patients' orientation, memory, concentration, language, and comprehension.

Psychological Safety

Psychological safety issues relate to self-destructive and violent behaviors or an inability to care for oneself. The clinician should ask direct questions about plans, means, and intent for violence. Plans include specificity of lethal methods, such as time and place. Means include implements such as medications, ropes, and guns. Intent refers to the desire or explicit goal to end either one's own or another's life.

In particular, patients should be asked about command hallucinations and delusions that direct the person to hurt him- or herself or another. Impaired judgment or cognition that may result in an increased likelihood of impulsive, destructive behaviors.

It is also important to ask patients about their past, and particularly recent, history of violent behaviors, since a history of suicidal and homicidal behaviors is the best predictor of current risk for such behaviors.

Assessing Psychological Safety

Social Safety

Patients should be asked direct questions about past and current access to basic needs such as food, shelter, money, medication, or clothing. Patients should be assessed for past and recent episodes of victimization and of exchanging sex for money, drugs, and shelter.

Comprehensive Assessment

It is essential to rule out imminently life-threatening medical or AOD-induced emergencies which may be causing or contributing to the psychotic symptoms.

Probing Questions for Psychiatric And AOD Abuse Assessment

Once medical and AOD-induced emergencies have been addressed or ruled out, the focus of probing assessment questions should relate to the severity of presenting behaviors and symptoms rather than to whether symptoms are primary or secondary to AOD use. The focus should be on assessing the severity of the immediate symptoms. With the exception of life-threatening emergencies, the clarification of "primary versus secondary" is an important issue in working with patients who have a dual disorder involving psychosis, but such clarification requires multiple-contact, longitudinal diagnostic differentiation.

Examples of key probing questions for delusions include the following:

Examples of key probing questions for AOD use disorders include:

It is important to recognize that direct interview questions will be of limited value for some patients in detecting substance use. Patients may underestimate, overestimate, or not recognize the severity or existence of their AOD use disorder.

Standardized Screening and Assessment Measures

There are several standardized instruments for AOD abuse screening and assessment. While valuable for assessing patients with AOD use disorders, these instruments have not been extensively tested among patients with concomitant psychotic and AOD use disorders. However, even brief instruments such as the CAGE questionnaire, the Michigan Alcohol Screening Test (MAST), and case manager rating scales will detect most AOD use disorders in this group.

Such instruments may be unreliable when used with patients who are acutely psychotic or whose residual impairments interfere with their capacity to respond to the interview questions. Since these tools involve self-report interviews, denial mechanisms may also reduce accuracy. Also, instruments that rely heavily on detecting signs of dependency syndromes (such as the Alcohol Dependency Scale) may fail to detect significant numbers of people with dual disorders. This is because even limited AOD use may be extremely problematic for patients with a psychotic disorder.

Especially for patients with psychotic symptoms, clinicians should inquire about the use, frequency, and quantity of all drugs of abuse, not merely alcohol. Also, clinicians can adapt the CAGE questionnaire (see Chapter 3) in such a way that the possible relation-ships between AOD use and psychotic symptoms can be elicited. For example, patients can be asked if they have cut down (or increased) their AOD use in relation to hearing "voices" or because of paranoia. They can be asked if they become more or less annoyed, angry, or irritable when using AODs. Clinicians can ask patients if they feel guilty about using AODs when taking medication, or if their guilt causes them to occasionally stop taking their medication.

Patients can be asked if AODs have been used to diminish the side effects of medications prescribed for psychiatric problems. Also, they should be asked if AOD use or withdrawal has ever been associated with a hospitalization or a suicide attempt. Patients should be asked if the frequency, quantity, and episode duration of their AOD use has changed and what consequences are associated with these changes.

Standardized assessment measures include the MAST, which has been demonstrated to have value for assessing this group. The Addiction Severity Index (ASI) is an instrument that guides the interviewer through a series of questions about drug use and consequences, as does the American Psychiatric Association's Structured Clinical Interview for DSM-III-R (SCID).

Alternatives to direct interview scales with demonstrated efficacy include case manager rating scales that are based on longitudinal observations of the patient, and aggregate multiple sources of information, including medical records, families, the criminal justice system, employers, landlords, and related sources. The patient's informed consent must be obtained before these contacts are made.

Clinician's Observations

An important aspect of the assessment is the clinician's observations. The clinician should make careful note of the patient's overall behavior, appearance, hygiene, speech, and gait. Of particular interest are any acute changes in these behaviors, as well as the emergence of disorganized or bizarre thinking and behavior. A long-term therapeutic relationship with the patient increases the opportunity to make clinical observations that assist in making the differential diagnosis. Within this context, clinicians can better understand the relationships between the AOD use and the psychiatric symptoms.

Collateral Resources

As previously mentioned, data obtained from direct interviews and self-reports, as well as observational data, are limited. One important way of augmenting these approaches is to obtain information from collateral sources by directly interviewing family members and significant others about the psychiatric and AOD-related behavior of patients. The family interview can also be a useful means to obtain further information regarding family history of psychiatric and AOD use disorders.

Other collateral information can include available documentation such as medical and criminal justice records, as well as information gathered from other sources such as landlords, housing settings, social services, and employers. Case managers may be in a unique position to compile aggregate reports from these various sources, since they are able to follow these patients over an extended period of time in a variety of settings.

Laboratory Tests

Laboratory tests for drug detection can be valuable both in documenting AOD use and in assessing AOD use in relation to psychotic symptoms. Objective urine and blood toxicology screens and alcohol Breathalyzer tests can be useful. Data from urine screens may be particularly useful for patients who deny regular use of AODs and who may benefit from objective feedback about the presence or absence of AOD use. Toxicology screens that document an absence of drug use can provide positive feedback for abstinent patients who are actively working to maintain sobriety.

Liver function tests have limited assessment value, particularly for patients ingesting large amounts of alcohol. However, the absence of abnormal liver findings should not be used as an indication of nonproblematic alcohol use.

Social Issues

While psychiatric, medical, or AOD-induced disorders may be more visible to the clinician than social problems, the latter can contribute significantly to the emergence and maintenance of these disorders. Indeed, the psychotic patient with dual disorders is more likely than not to have significant impairment in the social area. Thus, identifying the problem areas of a specific patient's social life becomes a core component of the service or treatment plan.

Actively helping patients to secure basic needs is a powerful way to engage them in the treatment process. Patients with dual disorders frequently face problems with living conditions, employment, homelessness, housing instability, loss of social support systems, and nutrition. The frustration and emotional turmoil that accompany problems in these areas can be intense. Indeed, many cases of treatment failure that are perceived as resistance to treatment and denial actually represent the failure of the treatment provider to recognize the impact of a patient's deteriorated social situation and to help the patient gain access to services.

In addition to social needs, clinicians should be aware of and sensitive to the impact of race, culture, ethnicity, nationality, gender issues, sexual orientation, and sexual history upon the lives of their patients.

Primary Health Care

A current or recent comprehensive medical evaluation is an essential aspect of the overall assessment. Nonmedical clinical personnel should become familiar with patients' medical histories and specifically inquire about the possible relationship between existing medical conditions and presenting symptoms.

Meeting the medical needs of patients with psychiatric and AOD use disorders is a critical aspect of treatment. For patients with psychotic disorders, attention to medical needs is even more important, since they generally have a high prevalence of medical problems, including chronic medical problems that are frequently untreated or undertreated.

During long-term treatment, it is important to evaluate the relationships between patients' medical problems and their psychotic and AOD use disorders. For example, medical problems may: 1) coexist with psychotic and AOD use disorders, 2) prompt or exacerbate psychotic and AOD use disorders, or 3) be the direct or indirect result of psychotic and AOD use disorders.

It is especially important for these patients to have easy access to treatment for medical conditions that are strongly associated with AOD use, such as tuberculosis, hepatitis, and HIV/AIDS. In addition, they should have easy access to treatment for basic medical needs, such as diabetes and hypertension, as well as cardiovascular, respiratory, and neurological disorders. Attention should be provided for the pregnant woman with regard to prenatal care and ongoing monitoring of pregnancy. The pregnant woman may be especially at risk for relapse when her regular antipsychotic medication regimen is contraindicated.

In addition to medical treatment, patients with dual disorders that involve psychosis need basic education about fundamental health care, hygiene, and AIDS prevention. A program that serves patients with dual disorders should include basic medical education components on site as a routine part of treatment, rather than referrals to another agency.

For patients who are prescribed medications, it is important to assess the types of medications, whether or not the medications are being taken, and the types of side effects they may cause. Patients should be asked specifically about the frequency, dosage, and duration of any prescription medication.

Medication noncompliance is the rule, not the exception, for people with dual disorders. Psychiatric medication noncompliance is particularly associated with dual disorders that involve psychosis, causing significant impact on presenting symptoms and level of function. Because of this common association between AOD use and noncompliance and the limitation of self-reports, it is useful to complement this assessment with an assessment of serum drug levels of psychiatric medications.

In addition to considering AOD use as a primary factor that affects the use of psychiatric medications, it is also important to consider the potential role of psychiatric medications in subsequent AOD use. For example, side effects such as akathisia (severe restlessness) or sedation may be caused by antipsychotic medications, and patients may take AODs in an attempt to medicate these unwanted side effects.

Frequently, psychoactive substances become replacements for adequate and nutritious food. Nutritional impairment is associated with impaired cognition. A lack of regular meals and poor nutrition are common occurrences among patients with dual disorders; thus, access to regular meals should be assessed.

Also, acute dental problems as well as ongoing dental care should be assessed. Because this group frequently experiences financial difficulties, access to dental care is often limited or nonexistent. Attention should be given to the social and emotional consequences of poor dental health, such as poor self-esteem and diminished social interaction.

Treatment Issues

The most important initial step in treatment is to identify high-risk conditions that require immediate treatment, while recognizing that there will likely be important issues that require long-term management.

Acute Management

Within the area of acute management, it is useful to differentiate between acute management of crises and the resolution of subacute problems that may be severe but not life threatening.

High-Risk Conditions

The initial critical consideration for high-risk conditions is to determine if patients require emergency medical treatment, psychiatric treatment, or both. The critical decision is whether patients require hospitalization, and if so, what type of treatment is required (for example, primary health care, detoxifi-cation, or psychiatric care). This aspect of treatment necessarily involves medical assessment and intervention.

With regard to biological or medical issues, the priority is addressing and stabilizing the acute crisis in a hospital-based setting. Once the acute crisis has been stabilized, mental health and AOD use consultation may be necessary to address the concomitant psychiatric and AOD disorders.

With regard to high-risk psychological conditions (that is, danger to self or others and other violent and impulsive behavior), the initial focus is on stabilizing the acute psychological crisis?providing that acute medical causes have been ruled out. Stabilization may require acute involuntary psychiatric hospitalization. Thus, coordination with emergency mental health services and the local police department is necessary to ensure the immediate safety of the patient and others.

With regard to high-risk social conditions (homelessness, housing instability, victimization, and unmet basic needs), the priority is on implementing aggressive social crisis intervention. Meeting patients' basic needs is critical in the management of the treatment of dual disorders that include psychosis. The high-risk social conditions may be related to the medical or psychiatric crisis, and therefore will require followup upon hospital discharge.

Regardless of the priority of crisis intervention, the overall biopsychosocial needs of patients must be addressed in a holistic manner, considering both the psychosis and the AOD use disorder. The approach must be integrated and comprehensive despite the higher visibility of one of the disorders.

Subacute Conditions

Following the resolution of the acute crisis, subacute conditions must be addressed before long-term management can occur. (Subacute conditions can also occur as a precursor to acute relapse of psychiatric symptomatology or AOD use.) Examples of specific subacute management issues include resuming or adjusting psychotropic medication, patients' comfort with the medication, medication compliance, addressing acute psychiatric symptoms, establishing early AOD use treatment intervention, and establishing or sustaining patients' connection with support systems and services for obtaining housing and meeting basic needs.

The subacute phase allows for an opportunity to reassess the diagnosis and overall treatment needs. The ultimate goal should be to establish a long-term treatment plan, to avert imminent decompensation or relapse, and to address long-term needs.

Long-Term Management

The overall goal of long-term management should involve: 1) providing coordinated and integrated services for both the psychiatric and AOD use disorders, and 2) doing so with a long-term focus that addresses biopsychosocial issues.

Patients with severe or persistent psychiatric and AOD use disorders, such as Thomas, require dually focused, integrated treatment. Patients like Martha, who have mild or brief symptoms of mental illness, may benefit from parallel treatment or self-help. Patients with AOD-induced psychiatric symptoms similar to Laura's should receive long-term management and treatment by AOD abuse treatment providers. Irrespective of the treatment setting, the goal is to help patients with dual disorders gain control over their psychiatric and AOD use disorders.

Gaining such control is a long-term process. For this group, the initial expectation during the engagement period should not be immediate compliance with psychiatric treatment or immediate abstinence. Indeed, mandating these treatment prerequisites may interfere with access to services or lead to the patient's rejection of the treatment services. Abstinence from AOD use is the long-term goal for patients with dual disorders that involve psychosis, but should not be a prerequisite for offering or continuing treatment services.

Therapeutic Engagement

The first step in the long-term treatment of patients with dual disorders that involve psychosis is to engage them in the treatment process. The basis of therapeutic engagement is building a relationship with patients. Engagement is a long-term process, not a single event that occurs only during the initial stages of treatment. The engagement process may need to be revisited throughout the course of treating these two unremitting disorders.

Frequently, patients with dual disorders do not acknowledge or appreciate that AOD use or a psychiatric disorder is a problem in their lives. Hence, establishing a relationship with these patients may first require knowing what they want and need. They may not want AOD treatment or psychiatric services. Rather, they may best be engaged by offering them assistance to meet their basic needs such as housing or entitlements or by providing basic medical and legal services.

A variety of approaches can be used to facilitate the engagement process. These include assertive outreach by case managers and clinicians, offering to facilitate the acquisition of basic services and entitlements and help with legal services. Similarly, engagement may be facilitated through involvement with alternative social and recreational activities, programs, clubs, and drop-in centers.

Engagement techniques can include the therapist's involvement with the family and other significant parties. Indeed, at times, clinicians may be able to maintain contact with patients only through the family.

Patients often want help finding and keeping a job. Thus, engagement includes vocational rehabilitation.

For patients who have particularly severe psychiatric or AOD use disorders and do not respond to these initial attempts at engagement in the treatment process, the use of therapeutic coercive approaches may be necessary. Patients with severe dual disorders may have gross cognitive impairment due to AOD use and may be severely disorganized due to psychiatric illness. They may be impulsive, exhibit extremely poor judgment, or be chronically dangerous to themselves or others.

Without therapeutic coercive interventions, some of these patients may be at substantial risk of catastrophic outcomes, including death, injury, violent behavior, or long-term incarceration. Examples of therapeutic coercive approaches include the appointment of a representative payee, guardian, or conservator and the use of parole or probation. Legal advocacy by a case manager for court-mandated treatment services may be essential for engaging and maintaining treatment services. Other mechanisms include commitment to outpatient treatment services, conditional discharge, and commitment to appropriate inpatient dual disorder treatment.

Therapeutic coercive efforts should be temporary and reserved for patients who have failed with other interventions. The long-term goal for these patients is to regain control over their lives. As mentioned above, service providers have traditionally expected patients to be motivated before initiating treatment. They have often misinterpreted the lack of engagement as denial or resistance to treatment.

It is essential for treatment professionals to understand that the provider is responsible for motivating or providing incentives for the patient to engage and remain in treatment.

Concurrent and Integrated Dually Focused Treatment

Service providers in traditional treatment programs have often maintained that patients with dual disorders should be treated sequentially, that is, by treating the AOD use disorder before treating the psychiatric disorder, or vice versa. Rather, there should be an ongoing dual focus on both disorders, especially for patients with psychosis or AOD use disorders.

Particularly for the severely disorganized patient or for the patient with persistently disabling conditions, integrated treatment is essential. Ideally, the services should be integrated within the same agency and program.

When mental health and addiction treatment services are not integrated, fragmentation of services and discontinuous service are significant risks. In situations where services cannot be integrated, it is crucial for one provider to accept full responsibility for the patient and to aggressively coordinate service with other programs and services. For treatment to be effective, and to ensure continuity of care, a long-term relationship and treatment approach should be developed.

For patients with milder psychiatric symptoms, parallel treatment approaches such as concurrent psychiatric and AOD treatment may be helpful, although such approaches have the disadvantage of placing the burden of integrating different treatment options on patients. This burden should be minimized by a case manager or clinician who can provide appropriate clinical liaison between different agencies.

Engaging the Chronically Psychotic Patient

Noncoercive Engagement Techniques

Coercive Engagement Techniques
  • Assistance obtaining food, shelter, and clothing
  • Assistance obtaining entitlements and social services
  • Drop-in centers as entry to treatment
  • Recreational activities
  • Low-stress, nonconfrontational approaches
  • Outreach to patient's community.
  • Involuntary commitment
  • Mandated medications
  • Representative payee strategies

Long-Term Perspective

For patients with dual disorders involving psychosis, a long-term approach is imperative. Research has shown that individuals become abstinent and gain control over psychiatric symptoms through a process that frequently takes years, not days or months. Front-loaded, intensive, expensive, and highly stimulating short-term treatment modalities are likely to fail with this group of patients.

Both psychotic and AOD use disorders tend to be chronic disorders with multiple relapses and remissions, supporting the need for long-term treatment. Also, an accurate diagnosis and an assessment of the role of AODs in the patient's psychosis necessitate a multiple-contact, longitudinal assessment and treatment perspective.

Treatment Teams

Especially for programs that treat patients with psychotic and AOD use disorders, it is essential that the program philosophy be based on a multidisciplinary team approach. Ideally, team members should be cross-trained, and there should be representatives from the medical, mental health, and addiction systems. Staff members should learn to use gentle or indirect confrontation techniques with these patients.

Assertive Case Management

Team members should endorse an assertive case management approach, wherein the case manager is not limited to the treatment site, but is expected to provide services to patients in their own environments. The case manager must not attempt to solely broker treatment services or exclusively provide office-based treatment. A supportive and psychotherapeutic approach to individual, group, and family work should be employed.

For these patients, flexible hours are necessary. Because crises frequently occur during evening and weekend hours, services should be provided during these hours. In addition, alternative social activities and peer group activities often take place in the evening and on weekends.

Also, individual and group programs for patients with dual disorders that involve psychosis should be based on a behavioral and psychoeducational perspective, not a psychodynamic approach. Educational information should be frequently repeated and presented in concrete terms using a multimedia format. Programs should be modified to include frequent breaks and shorter sessions than normal.

Special care should be taken with regard to patient education and group discussion about Higher Power issues. Staff members should be trained to teach patients and lead group discussions about spirituality and the concept of a Higher Power. Staff members should understand the difference between spirituality and religion, and especially the differences between spirituality, religion, and delusional systems that have a religious or spiritual content.

Personalized Service Planning

It is essential that the treatment plan for each patient be personalized, and based on the specific needs and stated goals of the patient, rather than on the clinician's goals. The patient should participate in the ongoing review and evaluation of the treatment plan.

Associated Psychosocial Needs

Even intensive, carefully designed AOD abuse treatment is likely to fail if the extensive psychosocial problems associated with dual disorders are not concurrently addressed. Common psychosocial concerns of this group include housing, finances and entitlements, legal services, job assistance, and access to adequate food, clothing, and medication.

Housing

A particularly common complication of dual disorder patients with psychosis is housing instability and homelessness. Among the possible housing services that may be particularly useful are shelters, supervised housing settings, congregated living settings, treatment milieu settings, and therapeutic communities. Ideally, residential options and placements should be long term, with the goal of promoting independent, stable, and safe housing.

Despite the long-term goal of sobriety, the housing needs of patients with chronic psychosis and AOD use disorders may be met temporarily by housing that is not explicitly drug free. Shelters or other forms of temporary housing that are not explicitly drug free but provide basic safety from weather and violence are better than no housing at all.

Various housing settings are necessary, including housing for current AOD-using individuals ("wet" or "damp" housing setting) and settings for individuals who are abstinent. Although there is a need for this broad range of housing, many communities do not currently have it. Within this range of agency-supported housing, there should be explicit policies regarding AOD use, understood by both the patient and the clinician.

It is also critical for treatment programs to have easy access to housing for patients with special needs, such as women and children, pregnant women, and battered women. Specific housing should be developed for patients with specialized, ongoing medical and psychological needs associated with complications of serious medical conditions such as AIDS.

Vocational Services

Vocational services are also essential for the long-term stabilization and recovery of the dual disorder patient. Both AOD and mental health services have traditionally referred clients to generic vocational rehabilitation services. These services must be integrated and modified for the specialized needs of the individual with psychosis and AOD use disorders. Temporary hire placements and job coaching options are important elements to incorporate into rehabilitation services for this group.

Sober Support Groups

An essential part of treatment for patients with dual disorders is the development of alternative peer group settings that do not include drug use. Developing these non-AOD-using social networks can be enhanced by programs that provide social club activities, recreational activities, and drop-in centers on site, as well as linkages to other community-based social programs. At the same time, patients should be encouraged to establish and maintain relationships, including family relationships, that are supportive of treatment goals.

Family

Treatment of the dual disorder patient can be substantially supported and enhanced by direct involvement of the patient's family. Services can include family psychoeducational groups that specifically focus on education about AOD use disorders and psychosis. This also includes multifamily treatment groups that may include the individual with the dual disorder.

Families may also be helpful in identifying early signs of psychiatric or AOD use relapse symptoms. They can work with the treatment team in initiating acute relapse prevention and intervention. Confidentiality issues need to be addressed at the beginning of treatment, with the goal of identifying a significant support person who has the patient's permission to be involved in the long-term treatment process.

Relapse Prevention

An essential component of relapse prevention and relapse management is close monitoring of patients for signs of AOD relapse and a return of psychotic symptoms. Relapse prevention also includes closely monitoring the development of patients' AOD refusal skills and their recognition of early signs of psychiatric problems and AOD use. The goals of relapse prevention are: 1) identification of patients' relapse signs, 2) identification of the causes of relapse, and 3) development of specific intervention strategies to interrupt the relapse process.

Close monitoring involves the long-term observation of patients for early signs of impending psychiatric relapse. Such signs may include the emergence of paranoid symptoms and symptoms related to AOD use such as hostile or disorganized behavior. For example, a sign of paranoid symptoms may be the patient's sudden and constant use of sunglasses. Additional important clues may involve changes in daily routine, changes in social setting, loss of daily structure, irritation with friends, and rejection of help. Family members who reside with the dual disorder patient are often the first to detect early signs of psychotic or AOD use relapse.

Additional signs of possible psychotic or AOD relapse include eviction from housing, job loss, or involvement with the criminal justice system. It is important that the clinician understand that routine daily stressors may have an intense impact on the dually diagnosed patient and may prompt relapse.

Objective laboratory tests may also be particularly useful in detecting early risk of AOD relapse. This includes the use of random urine toxicology screens, the alcohol Breathalyzer test, and blood tests to detect street drugs. As medication noncompliance is strongly associated with both AOD use and psychotic relapse, blood medication levels (including antipsychotic and lithium levels) may be particularly useful. Finally, intramuscular forms of antipsychotic medications may be particularly useful for verifying and assuring long-term compliance with antipsychotic medications.

In addition to close monitoring by health care professionals, family members, and significant others, an important component of relapse prevention is assisting the dual disorder patient to develop skills to anticipate the early warning signs of psychiatric and AOD use disorders. These skills can be acquired through direct individual psychoeducation and participation in role play exercises and psychoeducation groups. These patients should be trained to use AOD refusal skills and to recognize situations that place them at risk for AOD use.

Similarly, these patients may benefit significantly from behavioral therapy; development of relaxation, meditation, and biofeedback skills; exercise; use of visualization techniques; and use of relapse prevention workbooks. Pharmacologic strategies may include the use of disulfiram or naltrexone for certain patients.

Group Treatment

Group process is a core element of AOD abuse and mental health treatment. However, for patients with psychosis, group treatment should be modified and provided in coordination with a comprehensive service plan. The different types of groups specifically designed for the dual disorder patient include persuasion groups, active treatment groups, dual disorder-oriented 12-step groups (Double Trouble groups), pre-12-step groups, and groups that focus on medication and anger management.

Groups that are specifically designed for dual disorder patients are essential during the early phases of treatment. Patients who have accepted the goal of abstinence, have maintained psychiatric stability, and have essential social skills may benefit from carefully selected traditional 12-step programs that are sensitive to the needs of the severely mentally ill. However, during the early phases of treatment, an unfacilitated referral to traditional 12-step programs will likely result in treatment failure. (See the discussion on the use of the 12-step programs in Chapter 6.) A wide variety of group settings may be useful for the person with a dual disorder. However, the core approach should include psychoeducational, supportive, behaviorally oriented, and skill-building activities.

Medication

With patients who have dual disorders that involve psychosis, a common provider mistake that often leads to psychiatric or AOD use relapse involves a lack of attention to medication issues. Most important, treatment programs must provide aggressive treatment of medication side effects. Ignoring the side effects of prescribed medication often results in patients using AODs to diminish the unwanted medication side effects.

Equally important, patients should be educated and thoroughly informed about: 1) the specific medication being prescribed, 2) the expected results, 3) the medication's time course, 4) possible medication side effects, and 5) the expected results of combined medication and AOD use. Whenever possible, family members and significant others should be educated about the medication.

Medication should not simply be prescribed or provided to the psychotic patient with dual disorders. Rather, it is critical to discuss with patients 1) their understanding of the purpose for the medication, 2) their beliefs about the meaning of medication, and 3) their understanding of the meaning of compliance. It is important to ask patients what they expect from the medication and what they have been told about the medication. Overall, it is important to understand the use of medication from the patient's perspective. Indeed, informed consent relative to a patient's use of medication requires that the patient have a thorough understanding of the medication as described above.

It is also important to help patients prepare for peer reaction to the use of medication when they participate in certain 12-step programs. Patients should be taught to educate other people who may have biases against prescription medications or who may be misinformed about antipsychotic medications.

Patients receiving medication should participate in professionally led medication education groups and medication-specific peer support groups. These groups will help patients deal with the emotional and social aspects of medication, promote medication compliance, and help clinicians and patients identify and address early noncompliance and side-effect problems.

Overall, there must be a specific and aggressive treatment strategy that helps make medication use simple and comfortable. The scheduling and administration of medication should be simple and convenient for patients. The ideal schedule for oral medications is once per day. The use of injectable medications may be the most comfortable and effective option for some patients with dual disorders.

Anything that helps patients feel more comfortable about taking medication should be considered. In addition, an important treatment goal is a medication regimen that is self-monitoring.

When patients experience difficulty acquiring medication, the treatment program should directly help patients acquire them, not make referrals and recommendations.

Staff and Administrative Training

Traditional training in mental health and AOD abuse treatment, and in medicine in general, has been inadequate relative to the unique needs of the dual disorder patient. Thus, program staff require ongoing education about current understanding and treatment of dual disorders. It is imperative that the service principles of each discipline be presented and modified for application to people with dual disorders. Training also must be integrated, not sequential or parallel.

Perhaps the most important goal of clinical staff development and training is the cross-training of addiction and mental health personnel. Addiction specialists need training in psychiatric and mental health issues, while mental health and psychiatric specialists need training in AOD and addiction issues. In addition to cross-training, both addiction and mental health clinical staff require clinical and theoretical training in dual disorders.

Clinical staff training content must include information about the assessment and treatment of high-risk and subacute problems and about long-term treatment issues. There must be a focus on the interaction between AOD use and psychiatric symptoms. In addition, attention must be given to high-risk behaviors such as violence to self or others, suicide, impulsive behavior, and high-risk sexual behavior.

Clinical staff training must also address less obvious clinical issues such as cultural competency and sensitivity to the roles of culture, ethnicity, nationality, religion, and spirituality.

While 1- or 2-day workshops may be useful for disseminating clinical information, ongoing and routine education is critical. To emphasize the multidisciplinary team approach, staff education should be done in a group setting with interaction among group participants and trainers.

The need for clinical supervision among clinical staff is crucial. Supervision must be an ongoing, routine process, not driven by clinical crises. Nonetheless, because treatment of dual disorders involves frequent crises, the clinical supervisor must be readily available to team members and able to provide rapid coaching and support.

An important aspect of clinical supervision and clinical staff development is education in the theoretical basis of treatment. Irrespective of disciplines, all clinical staff must thoroughly understand and support the philosophical basis, values, and goals of the treatment program in which they work. Further, an important task of the clinical supervisor is to integrate the formal theory and principles within the specific treatment setting.

Clinical staff education and development must include the formation of procedures and supports to prevent staff burnout and demoralization. Components of staff burnout prevention include mechanisms for multidisciplinary group support, a focus on long-term rather than short-term gains for patients, anticipation and expectation of relapse as part of psychotic and AOD use disorders, and an understanding of relapse as a treatment opportunity rather than a treatment failure.

Program administrators, whether they are in contact with patients or not, require clinical education in dual disorder issues to provide an appropriate environment for the treatment of patients with dual disorders and to better understand the needs of staff and patients. Thus, program administrators require education in the latest conceptual and technological developments in the fields of psychiatry and AOD treatment as well as in dual disorders.

It is important for program administrators to regularly review, articulate, and discuss the program's philosophy, goals, and objectives with all program staff. Enhanced and open communication between administration and staff in both individual and group settings is also critical. For example, administrators should regularly communicate with staff regarding administrative constraints such as financial limitations, legal mandates, and political influences.

Administrators should thoroughly understand the appropriate role of clinical supervision: that this supervision is designed for skill enhancement and staff support. Clinical supervision skills are critical for providing effective services to high-risk populations such as patients with psychotic and AOD use disorders.

There should be open discussion of administrative styles, since these significantly affect staff morale and performance. Similarly, administrators should be aware of the influence of their personal characteristics upon staff and patients. For example, administrators should become aware of the influence that their culture, ethnicity, gender, sexual orientation, and background has on others.

Chapter 9 -- Pharmacologic Management

Pharmacologic Risk Factors

Addiction is not a fixed and rigid event. Like psychiatric disorders, addiction is a dynamic process, with fluctuations in severity, rate of progression, and symptom manifestation and with differences in the speed of onset. Both disorders are greatly influenced by several factors, including genetic susceptibility, environment, and pharmacologic influences. Certain people have a high risk for these disorders (genetic risk); some situations can evoke or help to sustain these disorders (environmental risk); and some drugs are more likely than others to cause psychiatric or AOD use disorder problems (pharmacologic risk).

Pharmacologic effects can be therapeutic or detrimental. Medication often produces both effects. Therapeutic pharmacologic effects include the indicated purposes and desired outcomes of taking prescribed medications, such as a decrease in the frequency and severity of episodes of depression produced by antidepressants.

Detrimental pharmacologic effects include unwanted side effects, such as dry mouth or constipation resulting from antidepressant use. Side effects perceived as noxious by patients may decrease their compliance with taking the medications as directed.

Some detrimental pharmacologic effects relate to abuse and addiction potential. For example, some medications may be stimulating, sedating, or euphorigenic and may promote physical dependence and tolerance. These effects can promote the use of medication for longer periods and at higher doses than prescribed.

Thus, prescribing medication involves striking a balance between therapeutic and detrimental phar-macologic effects. For instance, therapeutic antianxiety effects of the benzodiazepines are balanced against detrimental pharmacologic effects of sedation and physical dependency. Similarly, the desired therapeutic effect of abstinence from alcohol is balanced by the possibility of damage to the liver from prescribed disulfiram (Antabuse).

Side effects of prescription medications vary greatly and include detrimental pharmacologic effects that may promote abuse or addiction. With regard to patients with dual disorders, special attention should be given to detrimental effects, in terms of 1) medication compliance, 2) abuse and addiction potential, 3) AOD use disorder relapse, and 4) psychiatric disorder relapse (Ries, 1993a).

Psychoactive Potential

Not all psychiatric medications are psychoactive. The term psychoactive describes the ability of certain medications, drugs, and other substances to cause acute psychomotor effects and a relatively rapid change in mood or thought. Changes in mood include stimulation, sedation, and euphoria. Thought changes can include a disordering of thought such as delusions, hallucinations, and illusions. Behavioral changes can include an acceleration or retardation of motor activity. All drugs of abuse are by definition psychoactive.

In contrast, certain nonpsychoactive medications such as lithium (Eskalith) can, over time, normalize the abnormal mood and behavior of patients with bipolar disorder. Because these effects take several days or weeks to occur, and do not involve acute mood alteration, it is not accurate to describe these drugs as psychoactive, euphorigenic, or mood altering. Rather, they might be described as mood regulators.Similarly, some drugs, such as antipsychotic medications, cause normalization of thinking processes but do not cause acute mood alteration or euphoria.

However, some antidepressant and antipsychotic medications have pharmacologic side effects such as mild sedation or mild stimulation. Indeed, the side effects of these medications can be used clinically. Physicians can use a mildly sedating antidepressant medication for patients with depression and insomnia, or a mildly stimulating antipsychotic medication for patients with psychosis and hypersomnia or lethargy (Davis and Goldman, 1992). While the side effects of these drugs include a mild effect on mood, they are not euphorigenic. Nevertheless, case reports of misuse of nonpsychoactive medications have been noted, and use should be monitored carefully in patients with dual disorders.

While psychoactive drugs are generally considered to have high risk for abuse and addiction, mood- regulating drugs are not. A few other medications exert a mild psychoactive effect without having addiction potential. For example, the older antihistamines such as doxylamine (Unisom) exert mild sedative effects, but not euphoric effects.

Reinforcement Potential

Some drugs promote reinforcement, or the increased likelihood of repeated use. Reinforcement can occur by either the removal of negative symptoms or conditions or the amplification of positive symptoms or states. For example, self-medication that delays or prevents an unpleasant event (such as withdrawal) from occurring becomes reinforcing. Thus, using a benzodiazepine to avoid alcohol withdrawal can increase the likelihood of continued use. Positive reinforcement involves strengthening the possibility that a certain behavior will be repeated through reward and satisfaction, as with drug-induced euphoria or drug-induced feelings of well-being. A classic example is the pleasure derived from moderate to high doses of opiates or stimulants. Drugs that are immediately reinforcing are more likely to lead to psychiatric or AOD use problems.

Tolerance and Withdrawal Potential

Long-term or chronic use of certain medications can cause tolerance to the subjective and therapeutic effects and prompt dosage increases to recreate the desired effects. In addition, many drugs cause a well-defined withdrawal phenomenon after the cessation of chronic use. Patients' attempts to avoid withdrawal syndromes often lead them to additional drug use. Thus, drugs that promote tolerance and withdrawal generally have higher risks for abuse and addiction.

A Stepwise Treatment Model

As can be seen, there are pharmacologic as well as hereditary and environmental factors that influence the development of AOD use problems. All of these factors should be considered prior to prescribing medication, especially when the patient is at high risk for developing an AOD use disorder. High-risk patients include people with both psychiatric and AOD use disorders, as well as patients with a psychiatric disorder and a family history of AOD use disorders.

One aspect of this issue relates to the pharmacologic profile of certain medications that are used in the treatment of specific psychiatric disorders. For instance, many medications used to treat symptoms of depression and psychosis are not psychoactive or euphorigenic. However, many of the medications used to treat symptoms of anxiety, such as the benzodiazepines, are psychoactive, reinforcing, have potential for tolerance and withdrawal, and have an abuse potential, especially among people who are at high risk for AOD use disorders. Other antianxiety medications, such as buspirone (BuSpar), are not psychoactive or reinforcing and have low abuse potential, even among people at high risk.

Thus, decisions about whether and when to prescribe medication to a high-risk patient should include a risk-benefit analysis that considers the risk of medication abuse, the risk of undertreating a psychiatric problem, the type and severity of the psychiatric problem, the relationship between the psychiatric disorder and the AOD use disorder for the individual patient, and the therapeutic benefits of resolving the psychiatric and AOD problems.

For example, the early and aggressive medication of high-risk patients who have severe presentations of psychotic depression, mania, and schizophrenia is often necessary to prevent further psychiatric deterioration and possible death. For these patients, rapid and aggressive medication can shorten the length of the psychiatric episodes. In contrast, prescribing benzodiazepines to high-risk patients with similarly severe anxiety involves a substantial risk of promoting or exacerbating an AOD use disorder. For these high-risk patients, the use of psychoactive medication should not be the first line of treatment.

Rather, for some high-risk patients, treatment efforts should involve a stepwise treatment model that begins with conservative approaches and progressively becomes more aggressive if the treatment goals are not met (Landry et al., 1991a). For example, the stepwise treatment model for treating high-risk patients with anxiety disorders may involve three progressive levels of treatment: 1) nonpharmacologic approaches when possible; 2) nonpsychoactive medication when nonpharmacologic approaches are insufficient; and 3) psychoactive medications when other treatment approaches provide limited or no relief (Landry et al., 1991).

Pharmacologic Risk Factors

A medication may have:

A Stepwise Management Approach For Mild and Moderate Mental Disorders *

Step One: Try nonpharmacologic approaches

Step Two: Add nonpsychoactive medications if Step One is unsuccessful

Step Three: Add psychoactive medications if Steps One and Two are unsuccessful.

* For severe conditions, such as psychotic depression, mania, and schizophrenic disorders, rapid and aggressive use of medications is needed to prevent danger to self or others and further psychiatric deterioration.

Nonpharmacologic Approaches

Depending upon the psychiatric disorders and personal variables, numerous nonpharmacologic approaches can help patients manage all or some aspects of their psychiatric disorders (Weiss and Billings, 1988). Examples include psychotherapy, cognitive therapy, behavioral therapy, relaxation skills, meditation, biofeedback, acupuncture, hypnotherapy, self-help groups, support groups, exercise, and education.

Nonpsychoactive Pharmacotherapy

Some medications are not psychoactive and do not cause acute psychomotor effects or euphoria. Some medications do not cause psychoactive or psychomotor effects at therapeutic doses but may exert limited psychoactive effects at high doses (often not euphoria, but sometimes dysphoria).

For practical purposes, all of these medications can be described as nonpsychoactive, since the psychoactive effect is not prominent. Medications used in psychiatry that are not euphorigenic or significantly psychoactive include but are not limited to the azapirones (for example, buspirone), the amino acids, beta-blockers, antidepressants, monoamine oxidase inhibitors, antipsychotics, lithium, antihistamines, anticonvulsants, and anticholinergic medications.

Psychoactive Pharmacotherapy

Some medications can cause significant and acute alterations in psychomotor, emotional, and mental activity at therapeutic doses. At higher doses, and for some patients, some of these medications can also cause euphoric reactions. Medications that are potentially psychoactive include opioids, stimulants, benzodiazepines, barbiturates, and other sedative-hypnotics.

Stepwise Treatment Principles

One of the emphases of stepwise treatment is to encourage nondrug treatment strategies for each emerging symptom before medications are prescribed. Nondrug treatment strategies alone are inappropriate for acute and severe symptoms of schizophrenia and mood disorders, but nondrug strategies do have their place in the treatment of virtually any psychiatric problem, and may provide partial or total relief of some symptoms related to severe psychiatric disorders. For example, relaxation therapy can minimize or eliminate somatic symptoms of anxiety that may accompany an agitated depression.

A second emphasis of stepwise treatment is to encourage the use of medications that have a low abuse potential. This conservative approach must be balanced against other therapeutic and safety considerations in acute and severe conditions, such as psychosis or mania. On the other hand, a conservative approach is not the same as undermedication of psychiatric problems. Undermedication often leads to psychiatric deterioration and may promote AOD relapse. There should be a balance between effective treatment and safety.

A third emphasis of stepwise treatment is to encourage the idea that different treatment approaches should be viewed as complementary, not competitive. For example, if psychotherapy or group therapy does not provide complete relief from a situational depression (such as prolonged grief), then antidepressants should be considered as an adjunct to the psychotherapy, but not as a substitute for psychotherapy.

In practice, treatment providers often use a combination of drug and nondrug strategies. This practice includes medication to treat the acute manifestations of the disorder while the individual learns long-term management strategies. For example, an individual may be prescribed nonpsychoactive buspirone to reduce anxiety symptoms while learning stress reduction techniques and attending group therapy.

These guidelines are broad, general, and more applicable to chronic than to acute psychiatric problems. Also, these guidelines have limited application to very severe psychiatric problems.

Specific Medications and Recovery

Antihistamines

Several antihistamines are approved for sale as over-the-counter hypnotics, including diphenhydramine (Nytol, Benadryl), doxylamine (Unisom), and pyrilamine (Quiet World). The efficacy of these drugs is not uniform, and tolerance to the anxiolytic and hypnotic effects is rapid, limiting their utility for episodic use. Antihistamines are frequently prescribed for mild anxiety and insomnia, particularly for patients in general hospitals, patients with physical illness (Salzman, 1989), and elderly patients.

Antihistamines and Recovery

In general, the early antihistamines exert very mild anxiolytic and hypnotic effects, but lack euphoric properties and do not promote physical dependence (Meltzer, 1990). While lacking significant abuse potential themselves, antihistamines may cause problems for some patients by reinforcing the idea of self-medication of insomnia and anxiety. Taken in high doses, antihistamines may cause acute delirium, alter mood (often causing dysphoria), or cause morning-after depression. Under close medical supervision, the conservative use of antihistamines can be valuable in treating brief episodes of insomnia during an otherwise drug-free recovery process. Patients in recovery should be discouraged from purchasing and using over-the-counter antihistamines.

Antidepressants

The antidepressants include several types of medication, such as tricyclics, monoamine oxidase inhibitors (MAOIs), and other, newer, antidepressants such as trazodone (Desyrel), bupropion (Wellbutrin), sertraline (Zoloft), and fluoxetine (Prozac). Antidepressants are effective for the treatment of depression, and several are valuable for the treatment of anxiety disorders, including generalized anxiety disorder, phobias, and panic disorder.

Antidepressants and Recovery

The antidepressants are not euphorigenic, and do not cause acute mood alterations. Rather, they are mood regulators and diminish the severity and frequency of depressive episodes; they also have anti-panic capabilities unrelated to sedation.

While the general effects of most of the older tricyclic antidepressants are similar, they differ considerably with regard to side effects. For example, some antidepressants such as doxepin (Sinequan) exert a mild sedating effect, while others such as protriptyline (Vivactil) exert a mild stimulating effect. These side effects can be clinically useful. For example, clinicians might give antidepressants with slight sedating effects to depressed patients with insomnia or give those with mild stimulating effects to depressed patients who experience low energy and hypersomnia (Davis and Goldman, 1992).

Other side effects of tricyclic antidepressants are common. Anticholinergic effects such as dry mouth, blurred vision, constipation, urinary hesitancy, and toxic-confusional states are common anticholinergic effects. Adrenergic activation symptoms may include tremor, excitement, palpitation, orthostatic hypotension, and weight gain. These noxious side effects are frequently the cause of requests to switch from one medication type to another. Also, side effects often prompt discontinuation of medication, which may provoke reemergence of the psychopathology. Tricyclics unfortunately are quite toxic when combined with AODs. Therefore use of tricyclic antidepressants in early recovery should be carefully monitored.

More expensive, but much less toxic when used with AODs, are the newer serotonin reuptake inhibitors including fluoxetine, paroxitine (Paxil), and sertraline. These agents also have anticompulsive effects, and their side effects tend to be slight to moderate stimulation rather than sedation. They are much safer to use in early recovery.

Overall, the use of antidepressants is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and enhances recovery from depressive and panic disorders. However, patient information must include clear explanations of the reasons for prescribing, the expected results, and the risks of adverse effects, including overdose. The risk-benefit analysis must include the risk of lethal overdose with tricyclic antidepressants, especially for depressed patients (Reid, 1989).

Beta-Blockers

The beta-blockers such as propranolol (Inderal) are well-recognized medications for the treatment of hypertension, cardiac arrhythmias, and angina pectoris. They also have clinical efficacy as an adjunct in the treatment of anxiety (Lader, 1988). The b-blockers may reduce or eliminate the adrenergic discharge associated with panic attacks, thus blocking the somatic components of some anxiety states, especially when somatic symptoms predominate (Trevor and Way, 1989). b-blockers diminish the tremor and restlessness related to lithium or antipsychotics in some patients.

Beta-Blockers and Recovery

The Beta-blockers are not psychoactive, euphorigenic, or mood altering. Since tolerance to the anti-panic effects of b-blockers develops rapidly, they cannot be used for extended periods of time for this purpose. Rather, they are often used prophylactically for anticipated panic-producing situations, or for episodes of anxiety that may last a few days. The b-blockers are also used to decrease acute and subacute anxiety symptoms during detoxification from sedative-hypnotics such as the benzodiazepines. Overall, the use of b-blockers is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and can be an important adjunct to anxiety management.

Benzodiazepines

While all of the benzodiazepines have anxiolytic characteristics, they differ in their effectiveness in treating generalized anxiety disorder, mixed anxiety and depression, panic attacks, phobic-avoidance behaviors, and insomnia. In general, the benzodiazepines promote sedation, central nervous system depression, and muscle relaxation, and thus are effective for anxiety reduction and, at higher doses, for short-term management of insomnia.

The Benzodiazepines and Recovery

The benzodiazepines are psychoactive, mood altering, and reinforcing. Chronic use and subsequent cessation can cause withdrawal symptoms. Studies have shown that the benzodiazepines are not uniformly euphorigenic. Also, patients with a family and personal history of AOD abuse and addiction are more likely to experience euphoria with the benzodiazepines (Ciraulo et al., 1988, 1989).

Benzodiazepines are the most commonly used agents to moderate alcohol withdrawal and prevent dangerous withdrawal conditions such as delirium tremens and seizures. They are also widely used during detoxification from sedative-hypnotics. The benzodiazepines are frequently prescribed for use alone and in combination with antipsychotics during the treatment of acute psychotic symptoms caused by mania, schizophrenia, and drugs of abuse such as cocaine. Such treatment should be limited to the acute episode for most patients with dual disorders, so that one problem (psychosis) is not replaced by another problem (physical dependence or addiction). The benzodiazepines are not usually recommended for long-term use in patients with dual disorders unless all nonpsychoactive approaches have failed. That is, if all other less potentially adverse medications have proven inadequate and the benzodiazepines are indicated, then careful dispensing, regulation of dose, and scrupulous monitoring are required.

Overall, the use of benzodiazepines after the medical management of withdrawal is not consistent with a psychoactive-drug-free philosophy and may compromise recovery from addiction (Zweben and Smith, 1989). However, they can be used in the management of acute and severe withdrawal, panic, and psychosis with special guidelines in nonroutine situations.

Buspirone

Buspirone is the most well known of a new group of drugs (the azapirones) that selectively diminish multiple symptoms of anxiety without the acute mood alteration, sedation, or associated somatic side effects seen in the sedative-hypnotic anxiolytics. Buspirone is useful for generalized anxiety disorder, chronic anxiety symptoms, anxiety with depressive features, and anxiety among elderly patients. Buspirone is generally equivalent to the benzodiazepines with regard to anxiety management (Petracca et al., 1990; Strand et al., 1990). However, it takes several weeks for the maximal therapeutic effect of buspirone to occur.

Buspirone and Recovery

Buspirone is not psychoactive, mood altering, or euphorigenic (Balster, 1990). In particular, buspirone does not cause the mood alteration, central nervous system depression, sedation, and muscle relaxation associated with the benzodiazepines. However, many people with experience taking benzodiazepines may associate these mood alterations with relief of anxiety. As a result, patients who have experience with the benzodiazepines may misinterpret the absence of these side effects as evidence that the medication is ineffective. Educating patients about the distinction between anxiety reduction and sedation and about treatment expectations can avoid these misinterpretations.

Overall, the use of buspirone is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and enhances recovery from anxiety disorders.

Clonidine

Used in the form of a patch (Catapres Transdermal Therapeutic System patches) or tablets (Catapres), clonidine is well recognized as a treatment for symptoms of hypertension, including hypertensive symptoms that occur during withdrawal from depressant drugs, especially the opioids. In addition, clonidine appears to have anxiolytic and anti-panic properties comparable to the antidepressant imipramine. Patients may become less anxious but remain symptomatic. Some patients who have anxiety-depression or panic-anxiety experience significant antianxiety effects from clonidine. The anti-panic effect is the result of clonidine's ability to decrease locus ceruleus firing and thus decrease adrenergic discharge. Thus, clonidine may be useful for short-term use in the treatment of refractory anxiety with panic (Domisse and Hayes, 1987; Uhde et al., 1989).

Clonidine and Recovery

Clonidine is not psychoactive, euphorigenic, or mood altering. Clonidine may have significant antianxiety effects when administered to patients with anxiety-depression and panic-anxiety. However, tolerance to the anti-panic effects of clonidine can develop within several weeks. Thus, clonidine may be most useful for short-term use in the treatment of refractory panic disorder.

Overall, the use of clonidine is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and may be an adjunct in the treatment of anxiety symptoms.

Neuroleptic (Antipsychotic) Medications

The neuroleptic medications are most effective in suppressing the positive symptoms of psychosis such as hallucinations, delusions, and incoherence. In addition, they may help reduce disturbances of arousal, affect, psychomotor activity, thought content, and social adjustment (Africa and Schwartz, 1992). These psychotic symptoms may accompany schizophrenia, brief reactive psychosis, schizophreniform disorder, mania, depression, and organic mental disorders induced by AODs and medical conditions (Ries, 1993a).

Although neuroleptic medications are equally effective in suppressing psychotic symptoms, individuals may respond to one medication better than another. The chief differences among the neuroleptics relate to dosage, onset of effects, and (especially) side effects. Some side effects may be clinically useful, such as nighttime sedation with chlorpromazine or avoidance of appetite stimulation with molindone (Moban) (Africa and Schwartz, 1992).

In general, low-potency neuroleptics, for example, chlorpromazine, thioridazine (Mellaril), and clozapine (Clozaril), have significant sedative and hypotensive properties. Tolerance to these properties may develop within a few weeks. Also, low-potency neuroleptics are inherently anticholinergic, so that the use of additional anticholinergic drugs to prevent extrapyramidal symptoms may be unnecessary. The high-potency neuroleptics such as fluphenazine (Prolixin) and haloperidol (Haldol) cause more extrapyramidal side effects than the low-potency medications.

Neuroleptic Drug-Induced Extrapyramidal Symptoms

The extrapyramidal system is a network of nerve pathways that links nerves in the surface of the cerebrum (the deep mass of the brain), the basal ganglia deep within the brain, and parts of the brain stem. The extrapyramidal system influences and modifies electrical impulses that are sent from the brain to the skeletal muscles.

When this system is damaged or disturbed, execution of voluntary movements and muscle tone can be disrupted, and involuntary movements, such as tremors, jerks, or writhing movements, can appear. These disturbances are called extrapyramidal syndromes, which can be caused by all of the neuroleptic medications except clozapine.

Medicating Extrapyramidal Symptoms

Extrapyramidal symptoms are unwanted, noxious, and uncomfortable. Compliance with neuroleptic medications is worsened because of the onset of these drug-induced symptoms. A class of medications called anticholinergic agents can eliminate the muscle spasms in the neck, oral, facial, cheek, and tongue regions. Several other types of medications may also be helpful, including amantadine and beta-blockers.

Anticholinergic agents can also reduce the extrapyramidal movement disorder called akathisia, which consists of purposeless movements, usually of the lower extremities, often accompanied by the experience of severe, uncomfortable restlessness. These medications include benztropine (Cogentin), biperiden (Akineton), diphenhydramine (Benadryl), trihexyphenidyl (Antitrem), and procyclidine (Kemadrin). Patient response should be monitored because some anticholinergic medications may be mildly psychoactive for some AOD patients.

Neuroleptic Medications and Recovery

Neuroleptic drugs are not euphorigenic and do not cause acute mood or psychomotor alterations. However, side effects are common. Most of the neuroleptics cause sedation as a side effect, although adaptation to the sedative (but not the antipsychotic) effects develops within days or weeks. The anticholinergic side effects of neuroleptic medications can include dry mouth, constipation, and blurred vision. The neuroleptics can also cause extrapyramidal symptoms. The adverse side effects of neuroleptic medications are a frequent cause of medication compliance problems. These adverse effects can also prompt patients to use AODs to self-medicate noxious symptoms.

Because patients with psychotic symptoms often experience significant biopsychosocial problems, the neuroleptics allow them to engage in problem-solving and recovery-oriented interpersonal activities. Overall, the use of neuroleptics is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and enhances recovery from psychotic disorders.

Lithium

Lithium is the standard and first-line treatment for manic episodes, even though 10-14 days may be required before full effect is achieved. The initial symptoms managed by lithium include increased psychomotor activity, pressured speech, and insomnia. Later, lithium diminishes the symptoms of expansive mood, grandiosity, and intrusiveness. Lithium also treats signs related to disorganization of the form of thought such as flight of ideas and loosening of association.

Lithium and Recovery

Lithium does not cause acute mood alteration, and is not psychoactive or mood altering. Rather, lithium is a mood regulator, and diminishes symptoms of acute mania. The common adverse effects of lithium include thirst, urinary frequency, tremor, and gastrointestinal distress. Lithium allows patients who may have seriously disabling symptoms to engage in problem-solving and recovery-oriented interpersonal activities. Overall, the use of lithium is consistent with a psychoactive-drug-free philosophy, does not compromise recovery from addiction, and enhances recovery from bipolar disorders.

Anticonvulsants

Anticonvulsants have a role in the management of bipolar disorders, mania, schizoaffective disorder, and alcohol and benzodiazepine withdrawal. In addition, these medications may be prescribed for "flashbacks" related to drug use or post-traumatic stress disorder. These medications, such as carbamazepine (Tegretol) and valproic acid, are not psychoactive. The typically minor side effects of sedation and nausea may emerge as treatment is initiated. Rarely, carbamazepine causes a decrease in white blood cell count. Both medications are monitored according to blood levels. For the treatment of bipolar disorder, the anticonvulsants are most often used when lithium has failed. However, they are occasionally used by highly skilled physicians as first-line treatment. These medications are consistent with a psychoactive-drug-free philosophy, and may enhance the abilities of those who need them to participate in the recovery process.

Drug Interaction Cautions

There are certain risks associated with AOD use and withdrawal among patients who are also being administered medications to treat psychiatric disorders. Because of these risks, serious consideration should be given to inpatient treatment for withdrawal.

[Back Matter]

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Drug abuse as self-medication for depression: an empirical study. American Journal of Drug and Alcohol Abuse 18:121-129, 1992.
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Weissman, M.M.

The epidemiology of anxiety disorders: rates, risks and familial patterns. Journal of Psychiatric Research 22(Suppl. 1):99-114, 1988.
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Winter, A.S.

When Self-Help Isn't Enough. Washington, D.C.: Psychiatric Institutes of America Press, 1990.

Wolfe, H.L., and Sorensen, J.L.

Dual diagnosis patients in the urban psychiatric emergency room. Journal of Psychoactive Drugs 21(2):169-175, 1989.
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Yeary, J.R., and Heck, C.L.

Dual diagnosis: eating disorders and psychoactive substance dependence. Journal of Psychoactive Drugs 21(2): 239-249, 1989.
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Zweben, J.E.

Issues in the treatment of the dual-diagnosis patient. In: Wallace, B., ed. The Chemically Dependent: Phases of Treatment and Recovery. New York: Brunner/Mazel, 1992.

Zweben, J.E.

Counseling issues in methadone maintenance treatment. Journal of Psychoactive Drugs 23(2):177-190, 1991.
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Zweben, J.E., and Smith, D.E.

Considerations in using psychotropic medication with dual diagnosis patients in recovery. Journal of Psychoactive Drugs 21(2): 221-226, 1989.
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Appendix B -- Treatment of Patients With Dual Disorders: Sample Cost Data

To provide readers with illustrative data on the costs of running programs for patients with dual disorders, the consensus panel Chair obtained data on actual costs during fiscal year 1991-1992 from three programs in urban areas. One program, on the West Coast, provided day and evening intensive outpatient services. The second, in the Northeast, provided intensive outpatient services during the day. In the third program, in the Northwest, daytime intensive outpatient services, partial hospitalization, and intensive case management were provided.

Included in the tables below are descriptive data for each program, including institutional status (for example, private for-profit or public), payer mix (for example, Medicaid or self-pay patients), number of clients served (at 100 percent capacity), salary ranges of various levels of staff, and other expenses (for example, facility costs). Total expenses and total revenues for each program are listed at the end.

TREATMENT OF PATIENTS WITH DUAL DISORDERS SAMPLE COST DATA

 

Program 1

Program 2

Program 3

PROGRAM TYPE

 

 

 

 

 

 

Evening Intensive Outpatient

X

 

 

 

 

Day Intensive Outpatient

X

X

X

Partial Hospitalization

 

 

X

Other

 

 

Day treatment and intensive case management

REGION

West Coast

Northeast

Northwest

LOCALE

Urban

Urban

Urban

INSTITUTIONAL STATUS

 

 

 

 

 

 

Private for-profit

X

 

 

Private nonprofit

 

 

 

 

 

 

Public

 

X

X

Other

 

 

 

 

 

 

PAYER MIX (BY PERCENT)

 

 

 

 

 

 

Insurance/Managed Care

X

 

 

 

 

Medicaid

 

66%

30%

Medicare

X

 

25%

Self-pay

X

4%

 

 

HMO contract

X

 

 

 

 

State grant/purchase of care

 

30%

45%

 

 

Program 1

Program 2

Program 3

NUMBER OF PATIENTS SERVED (AT 100 PERCENT CAPACITY)

 

 

 

 

 

 

Daily

50+

45

100

Weekly

320

225

300

SALARY RANGES

 

 

 

 

 

 

Administrators/managers

$60,000 to 70,000

$38,000 to 50,000

$35,000 to 60,000

Physicians

$70/Hour to 100/Hour

$85,00

$70,000 to 90,000

Social workers

$30,000 to 50,00

$30,000

$26,000 to 35,000

Psychologists

$50,000 to 60,000

n/a

$50,000 to 70,000

Support staff

$18,000 to 27,000

$20,000 to 29,000

$22,000 to 28,000

Other

Addiction counselors, $23,000 to 35,000

Nurses, counselors and recreational therapists, $25,000 to 38,000

Addiction mental health specialists, $23,000 to 33,000

 

 

 

Nurses $32,000 to 48,000

 

 

Program 1

Program 2

Program 3

OTHER EXPENSES (BY PERCENT)

 

 

 

 

 

 

Administrative overhead

7.1%

24%

20%

Personnel (including fringe benefits)

80.5%

60%

70%

Facility costs

12.4%

16%

10%

 

 

TOTAL EXPENSES FY 1991-1992

TOTAL REVENUES FY 1991-1992

Program 1

$482,000

$489,000

Program 2

$811,052

$561,052

Program 3

$2,200,000

$1,980,000

Appendix C -- Federal Resource Panel

John J. Ambre, M.D., Ph.D.

American Medical Association

Robert Anderson

Director

Criminal Justice Service

National Association of State Alcohol and Drug Abuse Directors

Richard J. Bast

Public Health Advisor

Quality Assurance and Evaluation Branch

Division of State Programs

Center for Substance Abuse Treatment

Sandra M. Clunies, M.S., N.C.A.D.C.

President, Maryland Addiction Counselor Certification Board

Dorynne Czechowicz, M.D.

Associate Director

Medical and Professional Affairs

Division of Clinical Research

National Institute on Drug Abuse

Walter L. Faggett, M.D.

National Medical Association

Rita Goodman, M.S., R.N.C.

Nurse Consultant

Division of Primary Care Services

Health Resources and Services Administration

John Gregrich

Policy Analyst

Office for National Drug Control Policy

Executive Office for the President

Claudia Hart

American Psychiatric Association

Ruth H. Carlsen Kahn, D.N.Sc.

Special Projects Section

Division of Medicine

Bureau of Health Professions

Health Resources and Services Administration

Saul M. Levin, M.D.

Director

Office of Health Care Linkage

Center for Substance Abuse Treatment

Cherry Lowman, Ph.D.

Health Scientist Administrator

Treatment Research Branch

Division of Clinical and Prevention Research

National Institute on Alcohol Abuse and Alcoholism

Anna Marsh, Ph.D.

Associate Director for Evaluation

Office of Applied Studies

Center for Substance Abuse Treatment

Fred C. Osher, M.D.

Deputy Director

Office of Programs for the Homeless Mentally Ill

National Institute of Mental Health

Deborah Parham, Ph.D., R.N.

Chief

Special Initiatives

Policy and Evaluation Branch

Bureau of Primary Health Care

Health Resources and Services Administration

Kay Pearson, R.Ph., M.P.H.

Senior Health Policy Analyst

Agency for Health Care Policy and Research

Public Health Service

Bert Pepper, M.D.

The Information Exchange

New City, New York

Richard K. Ries, M.D. (Chair)

Director of Inpatient Psychiatry and Dual Disorder Programs

Harborview Medical Center

Seattle, Washington

Harry Schnibbe

Executive Director

National Association of State Mental Health Program Directors

Sarah Stanley, M.S., R.N., C.N.A, C.S.

American Nurses Association

Patricia M. Weisser

National Association of Psychiatric Survivors

Appendix D -- Field Reviewers

Arthur I. Alterman, Ph.D.

Scientific Director

Center for Studies of Addiction

University of Pennsylvania School of Medicine

Philadelphia, Pennsylvania

Robert Anderson

Director, Criminal Justice

National Association of State Alcohol and Drug Abuse Directors

Gloria J. Baciewicz, M.D.

Director

Alcoholism and Drug Dependency Program

University of Rochester Medical Center

Rochester, New York

Stephen J. Bartels, M.D.

Medical Director

West Central Services, Inc.

Research Associate

N.H. Dartmouth Psychiatric Research Center

Lebanon, New Hampshire

Richard J. Bast

Public Health Advisor

Center for Substance Abuse Treatment

Joseph J. Bevilaqua, Ph.D.

Director

South Carolina Department of Mental Health

Dolores M. Burant, M.D.

Program Director and Medical Director

University Outpatient Recovery Services

Madison, Wisconsin

Ricardo Castaneda, M.D.

Director

Inpatient Psychiatry at Bellevue Hospital

New York Medical Center

Nancy C. Carter

Director

Special Division for Alcohol and Drug Abuse Services

South Carolina Department of Mental Health

Maureen Connelly, Ph.D.

Professor

Department of Sociology and Social Work

Frostburg State University

Frostburg, Maryland

Marcelino Cruces, L.I.C.S.W.

Administrative Coordinator

Andromeda Transcultural Mental Health Center

Substance Abuse Treatment Division

Washington, D.C.

Dorynne Czechowicz, M.D.

Associate Director for Medical and Professional Affairs

Division of Clinical Research

National Institute on Drug Abuse

Robert E. Drake, M.D., Ph.D.

Professor/Director

N.H.-Dartmouth Psychiatric Research Center

Dartmouth Medical School

Lebanon, New Hampshire

Mary Katherine Evans, C.A.D.C., N.C.A.C. II

Treatment Coordinator

Evans and Sullivan

Beaverton, Oregon

Walter L. Faggett, M.D.

Pediatrics/Health Care Consultant

Capitol Area Health Services

National Medical Association

Denis Ferguson, M.A., C.S.A.D.C.

Program Manager

Substance Abuse Services

DuPage County Health Department

Wheaton, Illinois

James Fine, M.D.

Director

Addictive Disease Hospital at Kings County Hospital Center

Clinical Associate Professor

Department of Psychiatry

State University of New York

Health Service Center at Brooklyn

Brooklyn, New York

Agnes Furey, L.P.N., C.A.P.

Primary Care Coordinator

Florida Drug and Alcohol Abuse Program

Department of Health and Rehabilitation Services

Tallahassee, Florida

Harry W. Haverkos, M.D.

Acting Director

Division of Clinical Research

National Institute on Drug Abuse

Elizabeth A. Irvin, M.S.W.

Director of Service Integration

Department of Mental Health

Commonwealth of Massachusetts

Edward K. Katz, M.D., M.P.H.

Mind Science

Consultation for Problems in Thinking and Feeling

Stow, Ohio

Ruth H. Carlsen Kahn, D.N.Sc., R.N.

Special Projects Section

Division of Medicine

Bureau of Health Professions

Health Resources and Services Administration

George Kolodner, M.D.

Kolmac Clinic

Silver Spring, Maryland

Susan Krupnick, R.N., M.S.N., C.A.R.N., C.S.

Psychiatric Consultation Liaison Nurse

Department of Psychiatric Nursing

Hospital of the University of Pennsylvania

Fox Chase Manor, Pennsylvania

Robert M. Lichtman, Ph.D., C.A.C.

Associate Psychologist/Program Coordinator

Richmond Hill Outpatient Division

Creedmoor Psychiatric Center

Richmond Hill, New York

Herbert J. McBride

President and Medical Director

Re-Enter, Inc.

Philadelphia, Pennsylvania

Catherine Devaney McKay, M.D.

Chief Executive Officer

Connections Community Support Programs, Inc.

Wilmington, Delaware

Norman S. Miller, M.D.

Associate Professor of Psychiatry

Department of Psychiatry

University of Illinois at Chicago

Thomas Neslund

Executive Director

International Commission for the Prevention of Alcoholism and Drug Dependency

Silver Spring, Maryland

John Nielsen, L.P.C., C.C.D.C., M.S.S.

Alcohol and Other Drugs Counselor

Threshold Youth Services

Sioux Falls, South Dakota

Robert E. Nikkel, M.S.W.

Coordinator

Adult Program Services Team

Mental Health and Development Services Division

Office of Mental Health Services

State of Oregon

Fred C. Osher, M.D.

Acting Director for Demonstration Programs

Center for Mental Health Services

William C. Panepinto, A.C. S.W.

Assistant Director

Homelessness/Housing Unit

New York State Office of Alcoholism and Substance Abuse Services

T. Allan Pearson, M.S.W.

Mental Health, Alcohol, and Other Drug Abuse Counselor

Ozaukae County Department of Community Programs

Port Washington, Wisconsin

Walter E. Penk, Ph.D.

Chief

Psychology Services

Edit Nourse Rogers Memorial Veterans Hospital Bedford, Massachusetts

Harold I. Perl, Ph.D.

Public Health Analyst

Homeless Demonstration and Evaluation Branch

National Institute on Alcohol Abuse and Alcoholism

Ernest Quimby, Ph.D.

Assistant Graduate Professor

Department of Sociology and Anthropology

Howard University

Washington, D.C.

Kathleen Reynolds, M.S.W., A.C.S.W.

Associate Coordinator

Livingston/Washtenaw Substance Abuse Coordinating Agency

Washtenaw Community Mental Health

Ypsilanti, Michigan

Henry Jay Richards, Ph.D.

Associate Director for Behavioral Sciences

Patuxent Institution

Jessup, Maryland

Richard K. Ries, M.D.

Director of Inpatient Psychiatry and Dual Disorder Programs

Harborview Medical Center

Seattle, Washington

Bruce J. Rounsaville, M.D.

Associate Professor of Psychiatry

Division of Substance Abuse

Yale School of Medicine

New Haven, Connecticut

Harry Schnibbe

Executive Director

National Association of State Mental Health Program Directors

Bonnie Schorske, M.A.

Coordinator

Special Populations

New Jersey Division of Mental Health and Hospitals

Candace Shelton, M.S., C.A.C.

Clinical Director

Pascua Yaqui Adult Treatment Home

Tucson, Arizona

Elizabeth C. Shifflette, Ed.D.

Staff Development and Training Coordinator

South Carolina Commission on Alcohol and Drug Abuse

Virginia Stiepock, R.N., A.C.S.W., C.S.

Assistant Center Director/Clinical Director

Northern Rhode Island Community Mental Health Center, Inc.

Woonsocket, Rhode Island

Mathias E. Stricherz, Ed.D., C.D.C. III

Director

Student Counseling Center

University of South Dakota

Vermillion, South Dakota

J. Michael Sullivan, Ph.D.

Clinical Director

Evans and Sullivan

Beaverton, Oregon

Johnie L. Underwood, B.S., C.S.W.

Assistant Deputy Director

Division of Mental Health and Addictions

Indiana Family Social Services Administration

Mark C. Wallen, M.D.

Medical/Clinical Director

Livengrin Foundation, Inc.

Bensalem, Pennsylvania

Linda M. Washington, M.S.N., R.N., C.S.-P.

Psychiatric Nurse Clinical Specialist

Outpatient Addictions Services

Montgomery County Department of Addictions, Victims, and Mental Health Services

Rockville, Maryland

Patricia M. Weisser

National Association of Psychiatric Survivors

Sioux Falls, South Dakota

Sonya Cornell Yarmat, M.A.

Consultant

Division of Alcohol and Drug Abuse Services

Department of Social Rehabilitation

Topeka, Kansas

Doug Ziedonis, M.D.

Assistant Professor

Department of Psychiatry

Medical Director, Substance Abuse Treatment Unit

Outpatient Services

Yale University

New Haven, Connecticut

Joan Ellen Zweben, Ph.D.

Executive Director

East Bay Community Recovery Project

14th Street Clinic and Medical Group

Berkeley, California

Exhibits

Exhibit 2-1 DSM-III-R and DSM-IV Draft Criteria for AOD Dependence

DSM-III-R Criterion No.

DSM-IV Draft Criterion No.

Diagnostic Criterion (language from DSM-III-R)

No. 1

No. 3

AODs are often taken in larger amounts or over a longer period of time than the person intended.

No. 2

No. 4

The person has a persistent desire or has made one or more unsuccessful efforts to cut down or control AOD use.

No. 3

No. 5

The person spends a great deal of time in activities necessary to obtain, consume, or recover from AOD effect

No. 4

Deleted

The person experiences frequent intoxication or withdrawal symptoms when expected to fulfill major role obligations at work, school, or home, or when AOD use is physically hazardous.

No. 5

6

Important social, occupational, or recreational activities are given up or reduced because of AOD use.

No. 6

7

AOD use continues despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by AOD use.

No. 7

1

There is evidence of marked tolerance: a need for markedly increased amounts of AODs to achieve intoxication or a desired effect, or markedly diminished effect with continued use of the same amount.

No. 8

2

Evidence of characteristic withdrawal symptoms.

No. 9

2

AODs are often taken to relieve or avoid withdrawal symptoms.

Exhibit 3-1 Treatment Approach Similarities and Differences

 

Mental Health System

Dual Disorders Approach

Addiction System

Medications

Central to the management of severe disorders in acute, subacute, and long-term phases of treatment: antidepressants, antipsychotics, anxiolytics, mood stabilizers.

Central to the treatment of many patients with dual disorders. Caution is used when prescribing psychoactive, mood-altering medications.

Central for acute detoxification; less common for subacute phase. Few used during long-term treatment: disulfiram, naltrexone, methadone, and LAAM.

Therapeutic Confrontations

Minimal to moderate use, depending upon setting, patient, and problem. Not central to therapy.

Generally used, but use is modulated according to fragility of mental status.

Use by staffand peers is one of the central techniques in AOD treatment.

Group Therapy

Central to treatment.

Central to treatment.

Central to treatment.

12-Step Groups

Although historically underused, use is growing. Examples include: Emotions Anonymous, Obsessive-Compulsive Anonymous, and Phobics Anonymous.

Dual Disorders Anonymous groups not yet widespread. Use of 12-step groups for AOD problems is central, but actively psychotic or paranoid patients may not mix well in meetings. "Double Trouble" AA groups are becoming more numerous.

Use of 12-step groups is central to AOD treatment. Great availability. Examples include: Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous.

Other Self-Help Groups

Numerous national organizations. Growing numbers of local groups. Use depends upon availability and awareness. Examples include: Anxiety Disorders Association of America, National Depressive & Manic-Depressive Association, Recovery, Inc., and National Association of Psychiatric Survivors.

Use of self-help groups regarding AOD and mental health problems is increasing.

Numerous organizations and groups, often specialized. Examples include: Women for Sobriety, Rational Recovery, Secular Organizations for Sobriety, International Doctors in AA, Recovering Counselors Network, and Social Workers Helping Social Workers.

Exhibit 3-2 The CAGE and CAGEAID Questionnaires

The CAGE Questionnaire:

  • Have you ever felt you should cut down on your drinking?
  • Have people annoyed you by criticizing your drinking?
  • Have you felt bad or guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?

Source: Mayfield et al., 1974.

The CAGE Questions Adapted to Include Drugs (CAGEAID):

  • Have you felt you ought to cut down on your drinking or drug use?
  • Have people annoyed you by criticizing your drinking or drug use?
  • Have you felt bad or guilty about your drinking or drug use?
  • Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover or to get the day started?

Source: Brown, 1992.

Exhibit 5-1 Drugs That Precipitate or Mimic Mood Disorders

Mood Disorders

During Use [Intoxication]

After Use [Withdrawal]

Depression and dysthymia

Alcohol, benzodiazepines, opioids, barbiturates, cannabis, steroids (chronic), stimulants (chronic)

Alcohol, benzodiazepines, barbiturates, opiates, steroids (chronic), stimulants (chronic)

Mania and cyclothymia

Stimulants, alcohol, hallucinogens, inhalants (organic solvents), steroids (chronic, acute)

Alcohol, benzodiazepines, barbiturates, opiates, steroids (chronic)

Exhibit 7-1 Characteristics of People With Passive-Aggressive, Antisocial, and Borderline Personality Disorders

Characteristic

Passive-Aggressive

Antisocial

Borderline

Affect

Overcontrolled hostility

Angry intimidation

Angry self-harm

World-view

I do everything right and they still act this way. I don't deserve this. I'm fine; ignore the tears.

If you don't do what I want, you'll be sorry. I deserve it all. They're the ones with the problem.

I've got to get you, before you get me. I don't deserve to exist. Help me, help me, but you can't.

Presenting problem

Depression, somatization, sedative dependence, codependency relationships

Legal difficultie polysubstance abuse and dependence, parasitic cold relationships

Self-harm, impulsive behavior, episodic polysubstance abuse.

Social functioning

Consistent underachievement

Episodic achievement

Gross dysfunctioning

Motivation

Belonging

Self-esteem

Safety

Defenses

Repression

Rationalization, projection

Splitting, projection

Adapted with permission from Evans, K., and Sullivan, J.M. Step Study Counseling With the Dual Disordered Client. Center City, Minnesota: Hazelden Educational Materials, 1990.

Exhibit 7-2 Step Work Handout For Patients With Borderline Personality Disorder

Step One: "We admitted we were powerless over alcohol-that our lives had become unmanageable."

  • Describe five situations where you suffered negative consequences as a result of drinking or using other drugs.
  • List at least five "rules" that you have developed in order to try to control your use of alcohol or other drugs. (Example: "I never drink alone.")
  • Give one example describing how and when you broke each rule.
  • Check the following that apply to you:
    • I sometimes drink or use other drugs more than I plan.
    • I sometimes lie about my use of alcohol or other drugs.
    • I have hidden or stashed away alcohol or other drugs so I could use them alone or at a later time.
    • I have had memory losses when drinking or using other drugs.
    • I have tried to hurt myself when drinking or using other drugs.
    • I can drink or use more than I used to, without feeling drunk or high.
    • My personality changes when I drink or use other drugs.
    • I have school or work problems related to using alcohol or other drugs.
    • I have family problems related to my use of alcohol or other drugs.
    • I have legal problems related to my use of alcohol or other drugs.
  • Give two examples for each item that you checked.

Step Two: "We came to believe that a Power greater than ourselves could restore us to sanity."

  • Give three examples of how your drinking or use of other drugs was insane. (One definition of insanity is to keep repeating the same mistake and expecting a different outcome.)
  • Check which of the following mistakes or thinking errors that you use:
    • Blaming
    • Lying
    • Manipulating
    • Excuse making
    • Beating up yourself with "I should have" statements
    • Self-mutilation (cutting on yourself when angry)
    • Negative self-talk
    • Using angry behavior to control others
    • Thinking "I'm unique."
  • Explain how each thinking error you checked above is harmful to you and others.
  • Give two examples of something that has happened since you stopped drinking or using other drugs that shows you how your situation is improving.
  • Who or what is your Higher Power?
  • Why do you think your Higher Power can be helpful to you?

Step Three: "Made a decision to turn our will and our lives over to the care of God as we understood Him."

  • Explain how and why you decided to turn your will over to a Higher Power.
  • Give two examples of things or situations you have "turned over" in the last week.
  • List two current resentments you have, and explain why it is important for you to turn them over to your Higher Power.
  • How do you go about "turning over" a resentment?
  • What does it mean to turn your will and life over to your Higher Power?
  • Explain how and why you have turned your will and life over to a Power greater than yourself.

Step Four: "Made a searching and fearless moral inventory of ourselves."

  • List five things you like about yourself.
  • Give five examples of situations where you have been helpful to others.
  • Give three examples of sexual behaviors related to your drinking or use of other drugs, which have occurred in the last 5 years, about which you feel bad.
  • Describe how beating yourself up for old drinking and other drug-using behavior is not helpful to you now.
  • List five current resentments you have, and explain how holding on to these resentments hurts your recovery.
  • List all laws you have broken related to your drinking and use of other drugs.
  • List three new behaviors you have learned that are helpful to your recovery.
  • List all current fears you are experiencing, and discuss how working the first three Steps can help dissolve them.
  • Give an example of a current situation you are handling poorly.
  • Discuss how you plan to handle this situation differently the next time the situation arises.

Adapted with permission from Evans, K., and Sullivan, J.M. Step Study Counseling With the Dual Disordered Client. Center City, Minnesota: Hazelden Educational Materials, 1990.

Exhibit 7-3 Recovery Model for the Treatment Of Borderline Personality Disorder

Stage

Indications

Goal

Interventions

I. Crisis

Behavior out of control; risk of harm to self or others; extreme withdrawal or intrusiveness

Safety and health through structure and support

  • Inpatient stay
  • Contracts for safety
  • Case manager or support groups
  • Identify triggers for relapse or stress to plan for crisis
  • Make daily or weekly schedule to structure time

II. Building

Routine attendance at therapeutic sessions, meetings, appointments; some ability to stay focused on here and now

Increasing coping skills and self-esteem

  • Develop an assets or accomplishments list
  • Positive self-talk and affirmations
  • Skills training in time management, assertiveness, and so on

III. Education

Expresses, exhibits increased self-efficacy

Reframe self-perceptions and history from victim to survivor

  • Read or debrief clinician-prescreened ACOA or incest-survivor literature
  • Classes on dysfunctional families, survivor issues
  • Written assignments on strengths and limitations of "survivor behaviors"

IV. Integration

Able to express feelings

Integrate past, present, and regulate thinking and actions behaviors

  • Art therapy, journal work, current feelings, thoughts, other expressive modalities
  • Psychodynamic therapy, here-and-now interpretations
  • Grief and child-within work, marital, sex, or family therapy

Adapted with permission from Evans, K., and Sullivan, J.M. Step Study Counseling With the Dual Disordered Client. Center City, Minnesota: Hazelden Educational Materials, 1990.

Exhibit 7-4 Antisocial Thinking-Error Work

The group facilitator will present thinking errors and then ask each group member to identify two thinking-error examples that apply to him or her and to choose one to focus on with group help.

  1. Excuse making -- Excuses can be made for anything and everything. Excuses are a way to justify behavior. For example: "I drink because my mother nags me," "My family was poor," "My family was rich."
  2. Blaming -- Blaming is an excuse to avoid solving a problem and is used to excuse behavior and build up resentment toward someone else for "causing" whatever has happened. For example: "They forced me to drink it!"
  3. Justifying -- To justify an antisocial behavior is to find a reason to support it. For example: "If you can, I can," "I deserve to get high," "I've got 30 days clean."
  4. Redefining -- Redefining is shifting the focus on an issue to avoid solving a problem. Redefining is used as a power play to get the focus off the person in question. For example: "I didn't violate my probation. The language is confusing and the order is full of typos."
  5. Superoptimism -- "I think; therefore it is." Example: "I don't have to go to AA. I can stay sober on my own."
  6. Lying -- There are three basic kinds of lies: (1) lies of commission -- making things up that are simply not true; (2) lies of omission -- saying partly what is so, but leaving out major sections, and (3) lies of assent -- pretending to agree with other people or approving of their ideas despite disagreement or having no intention of supporting the idea.
  7. "I'm Unique" -- Thinking one is special and that rules shouldn't apply to one.
  8. Ingratiating -- Being nice to others, and going out of one's way to act interested in other people, can be used to try to control situations or get the focus off a problem. Apple polishing.
  9. Fragmented Personality -- Some people may attend church on Sunday, get drunk or loaded on Tuesday, and then attend church again on Wednesday. They rarely consider the inconsistency between these behaviors. They may feel that they have the right to do whatever they want, and that their behaviors are justified.
  10. Minimizing -- Minimizing behavior and action by talking about it in such a way that it seems insignificant. For example: "I only had one beer. Does that count as a relapse?"
  11. Vagueness -- This strategy is to be unclear and nonspecific to avoid being pinned down on any particular issue. Vague words are phrases such as: "I more or less think so," "I guess," "probably," "maybe," "I might," "I'm not sure about this," "it possibly was," etc.
  12. Power Play -- This strategy is to use power plays whenever one isn't getting one's way in a situation. Examples include walking out of a room during a disagreement, threatening to call an attorney or report the group facilitator to higher-ups.
  13. Victim Playing -- The victim player transacts with others to invite either criticism or rescue from those around him.
  14. Grandiosity -- Grandiosity is minimizing or maximizing the significance of an issue, and it justifies not solving the problem. For example: "I was too scared to do anything else but sit," "I'm the best there is, so no one else can get in my way."
  15. Intellectualizing -- Using an emotionally detached, data-gathering approach to avoid responsibility. For example, when faced with a positive urine drug screen the patient states: "When was the last time the laboratory had their equipment calibrated?" or "What is the percentage of error in this testing procedure?"

Adapted with permission from Evans, K., and Sullivan, J.M. Step Study Counseling With the Dual Disordered Client. Center City, Minnesota: Hazelden Educational Materials, 1990.

Exhibit 7-5 Step Work Handout For Patients With Antisocial Personality Disorder

Step One: "We admitted we were powerless over alcohol -- that our lives had become unmanageable."

  • Give five examples of ways you have tried to control your use of chemicals and failed.
  • Give five examples of people you have tried and failed to control, and explain why your controlling behavior was unsuccessful (minimum of 150 words each).
  • Give five examples of situations not associated directly with drinking or using other drugs where you have tried to control things and failed (minimum of 100 words each).
  • Give two examples of people who currently have control over you, and explain how that is helpful to you (minimum of 100 words each).
  • Give ten examples of how your drinking and using other drugs caused you problems (minimum of 25 words each).
  • Give five examples of negative consequences that await you should you continue using or abusing alcohol or other drugs (minimum of 50 words each).

Step Two:"Came to believe that a Power greater than ourselves could restore us to sanity."

  • Repeating the same mistake over and over when you continually receive negative consequences is one definition of insanity. From the list below, identify your "mistakes" (place a check mark on the line next to each "mistake" that applies). Then, below the list, explain how each of these mistakes in your thinking has caused you problems.
    • Excuse making
    • Minimizing
    • Blaming
    • Intentionally being vague
    • Using anger and threats
    • Superoptimism
    • Using power plays
    • Playing the victim
    • Making fools of others
    • Love for drama and excitement
    • Assuming what others think and feel
    • Not listening to others and being closed-minded
    • Thinking "I'm unique"
    • Maintaining an "image"
    • Being ingratiating (kissing up)
    • Being grandiose
    • Lying: commission, omission, assent
  • List three people with whom you are angry and explain how they can be helpful.
  • List five people more powerful than you who can help you stay clean and sober. Explain why and how each person can help.
  • Who or what is your Higher Power?
  • Describe how this Higher Power can help you with your mistakes in thinking.

Step Three: "Made a decision to turn our will and our lives over to the care of God as we understood Him."

  • How did you decide that you needed to turn your will over to a Higher Power?
  • Why is it important for you to turn your will and life over to a Higher Power?
  • Explain how you go about "turning it over."
  • Give three examples of things you have had to "turn over" in the last week.
  • Give three examples of things you have yet to turn over and explain how and when you plan to do so.
  • What does it mean to "turn your will and life over to your Higher Power"?
  • Without displaying any thinking errors, explain how and why you have turned your will and life over to a Power greater than yourself.

Step Four: "Made a searching and fearless moral inventory of ourselves."

  • List any and all law violations you have committed regardless of whether or not you were caught for these crimes.
  • List every person you have a resentment against, and explain how this resentment is hurting you.
  • Give ten examples of sexual behavior you engaged in that was harmful to your partner, and explain the negative consequences to you of this behavior.
  • Give five examples of aggressive behavior (either verbal or physical) you have been involved in, and explain how it was hurtful to the other person and to you.
  • List five major lies you have told, and explain how that lying was hurtful to you.
  • List three lies you have told within the last 48 hours, and explain how this lying hurts your recovery program.

Adapted with permission from Evans, K., and Sullivan, J.M. Step Study Counseling With the Dual Disordered Client. Center City, Minnesota: Hazelden Educational Materials, 1990.
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