Comorbidity of addictive behavior and mental disorder: Outpatient practice guidelines (for those who prefer not to treat addictive behavior)

COGNITIVE AND BEHAVIORAL PRACTICE 1,

93-109,

1994

Comorbidity of Addictive Behavior and Mental Disorder: Outpatient Practice Guidelines (For Those Who Prefer Not To Treat Addictive Behavior)

Arthur T. Horvath

La Jolla, California

Guidelines are presented for treating the patient with both addictive behavior (AB) and mental disorder (MD) who refuses referral to specialized AB treatment. These guidelines are based on a cognitive-behavioral therapy (CBT) model of AB. The CBT model avoids conflicts associated with providing a psychological treatment for MD and a disease model treatment for AB. Many CBT AB interventions can be provided by a psychotherapist who does not specialize in AB. These interventions may be sufficient treatment, or may motivate the patient to obtain specialized AB treatment. M o s t general practice psychotherapists have not received substantial training in the t r e a t m e n t of addictive behavior. A p r o b l e m arises because m a n y psyc h o t h e r a p y outpatients, in a d d i t i o n to their other problems, also exhibit addictive behavior. A l t h o u g h referring such patients would a p p e a r to be an obvious solution, m a n y of these patients m a y not accept a referral to other providers o r types of treatment. F u r t h e r m o r e , specialized t r e a t m e n t p r o g r a m s for a patient's p a r t i c u l a r c o m b i n a t i o n of behavioral, emotional, a n d addictive p r o b l e m s m a y not be available locally, or anywhere. I n a t t e m p t i n g to best serve such a patient, the psychotherapist m i g h t often be unsure a b o u t how to c o m p r o m i s e between not treating the patient, on the one hand, a n d providing possibly insufficient treatment, on the other. This p a p e r offers guidelines for coping with this d i l e m m a . 93

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Copyright 1994 by Associationfor Advancement of Behavior Therapy All rights of reproduction in any form reserved.

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This dilemma is based in part on the attitude of many psychotherapists. Many general practitioners' thinking on the subject of treating addictive behavior can apparently be summarized as follows: I treat mental disorder (MD), not addictive behavior (A_B). If during initial assessment I identify a patient with AB, I refer to specialized treatment. However, occasionally a patient slips through my screening process. When my recognition of the AB eventually occurs (e.g., treatment is not progressing and I am looking for explanations, the patient trusts me more and reveals more, I belatedly begin to "get the picture" as more clues emerge, etc.), I am then often stuck. If the AB is interfering with my treatment plan, do I discontinue treatment pending successful completion of AB treatment? Is it realistic for the patient to participate in my treatment and AB treatment simultaneously? If the patient refuses the referral (as often happens), should I refuse to continue treatment, so as not to "enable" the AB? Should I make compliance with the referral the only focus of treatment? If I continue attempting to accomplish my original treatment plan, but treatment is obviously not working because of the AB, how long should I continue before giving up? Should I attempt to integrate the AB into my treatment plan, even though I have less than ideal experience in treating AB? How can I more effectively screen out these patients in the first place to avoid this mess? In this paper I draw from the empirical literature and clinical experience to suggest answers to these questions. These answers will be most pertinent to the psychotherapist who to some degree holds the belief"I treat MD, not AB" M y perspective is that of a private practice psychologist who works primarily with non-psychotic adult outpatients, many of whom have a "dual diagnosis" (i.e., both M D and AB). First I review recent conceptual developments and empirical findings relevant to this type of dual diagnosis. Then I present recommendations on how the psychotherapist who does not specialize in AB can address dual diagnosis in outpatient practice.

Recent Conceptual Developments The following perspective on behavioral healthcare lays a foundation for concluding that the belief "I treat MD, not AB" may be increasingly untenable. Behavioral Healthcare Is Reunifying The existence of dual diagnosis is primarily a statement about providers and their identities. What is significant about the term "dual" is not two (or more) diagnoses, but the presence of a diagnosis from each of two different treatment perspectives: In this case, mental health and substance (alcohol and drug) abuse. Developmental disability providers use dual diagnosis to describe a patient with a mental health diagnosis and mental retardation. Healthcare providers use dual diagnosis to describe a patient with both a mental and physical diagnosis. Alcohol and drug treatment providers (who tend to consider themselves more dis-

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tinct from each other than many mental health professionals realize) use dual diagnosis to describe a patient with both a drug and alcohol diagnosis. The existence of three National Institutes, NIAAA (National Institute on Alcohol Abuse and Alcoholism), NIDA (National Institute on Drug Abuse), and N I M H (National Institute of Mental Health), illustrates how fragmented behavioral healthcare has been. The term comorbidity, although potentially more precise than dual diagnosis, apparently does not include the significance of crossing different treatment perspectives. The breakup of behavioral healthcare into three components occurred decades ago. One factor contributing to this breakup was the (believable) perception of individuals recovered from AB that mental health professionals had not served them well in their efforts to recover, primarily by focusing on presumed underlying causes of the AB, but not treating the AB itself. The alcohol and drug fields reacted by tending to ignore underlying causes and focusing primarily on the AB. Many mental health providers, being excluded from traditional alcohol and drug programs, have apparently come to believe that they do not belong there ("I treat MD, not AB"). The dual diagnosis patient is a challenge to the beliefs of all three groups. There have been several recent recommendations to providers of alcohol, drug, or mental health services to consider their dual diagnosis patients from the other two perspectives (Clark & Zweben, 1989; Cohen & Levy, 1992; Nikkel & Coiner, 1991; Polcin, 1992). Until patients are treated within a single framework, they will be caught, to their detriment, in conflicts about the importance of self-control, the role of medication, the ultimate causes of their problems, the role of professional help, and so forth. As more providers attempt to unite these three perspectives, behavioral healthcare will become reunified. Although some have suggested that dual diagnosis become essentially a fourth perspective, further differentiation is unlikely to resolve a problem that arose because of differentiation (Schmidt, 1991). The establishment in 1993 of Division 50 (Addictions) of the American Psychological Association exemplifies how much reunification has already occurred. A Comprehensive Cognitive-Behavioral Therapy Model for Addictive Behavior Is Emerging The dominant model of AB treatment in the United States has been a hybrid of viewing these problems as a disease, a moral problem, a spiritual problem, and (to a lesser extent) a learning problem (Brower, Blow, & Beresford, 1989; Marlatt, 1985a). Although the moral and spiritual approaches may be matters of faith, whether AB is a disease is an empirical question. Reviews of the rele~ vant research, both scholarly and popular, are widely available (e.g., Fingarette, 1988; Institute of Medicine, 1990; Marlatt, 1983; 1985a; Miller, 1993; Peele, 1989). Marlatt (1983, p. 1107) concludes that "there is no adequate empirical

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substantiation for the basic tenets of the classic disease concept of alcoholism." Fingarette (1988, p. 3) concludes that "no leading research authorities accept the classic disease concept [emphasis in original]" After reviewing the disease model's difficulty accounting for various empirical findings (e.g., that alcoholism is not always incurable, is not an all-or-none disorder, and is not based solely on hereditary physical abnormalities), Miller (1993, p. 135) concludes that "this model is simply inadequate for the task of describing, understanding, and addressing alcohol problems in society." Emerging as an alternative to the disease model is a cognitive-behavioral therapy (CBT) model. C B T methods for AB treatment have been developed suiTlciendy to be manualized (Kadden et al., 1992; Miller, Zweben, DiClemente, & Rychtarik, 1992), and to be described in widely accepted texts (Marlatt & Gordon, 1985; Miller & Rollnick, 1991; Monti, Abrams, Kadden, & Cooney, 1989). Abrams and Niaura (1987) provide a theoretical overview. The CBT model has a number of significant differences from the disease model of AB: (1) AB is understood as an adaptive effort gone awry; (2) AB could arise from the use of a wide range of substances (including prescription medication, caffeine, nicotine, etc.); (3) AB lies on a continuum, with diagnosable AB being only part of the continuum; (4) Treatment is considered an adjunct to natural recovery-- the processes occurring in the natural environment that ultimately result in what at a distance appears as spontaneous remission (Robins, 1993; Sobell, Sobell, & Toneatto, 1991); (5) Rational Recovery is the preferred support group (Trimpey, 1989); and (6) Stable moderation of use is considered a realistic outcome for selected individuals (Sanchez-Craig, 1984). One additional characteristic ofa C B T model of AB is that AB can be understood to include activities (e.g., chronic gambling, promiscuous sexuality, chronic overspending, etc.) and eating disorders, as well as substance use (Miller & Heather, 1986). Because the delineation of the similarities and differences between activity AB, substance AB, and eating disorders has only recently been explored, and because substance AB's have the most substantial history of being considered as a group, this paper has been delimited to focus on substance AB. Nevertheless, the practice guidelines offered here may also apply to activity AB and eating disorders. It is important to note that the term AB can be used at various levels of abstraction. There may be many clinically significant differences between the same patient's AB at different times, between two patients with the same AB (e.g., alcohol dependence), or between two patients with substance AB (e.g., cocaine abuse vs. marijuana abuse). Although an important emphasis in this paper is on similarities across AB (possibly including activity AB and eating disorders), this emphasis is not intended to minimize the differences that also exist. It is a substantially smaller step for a psychotherapist trained in a CBT model of M D treatment to extend these skills to treating AB, than to learn a significantly different treatment model. A CBT psychotherapist skilled in the treat-

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ment of both M D and AB could treat dual diagnosis patients using a consistent theoretical framework.

Empirical Findings Dual Diagnosis Is Common If by dual diagnosis we mean the simultaneous presence of at least one psychoactive substance use disorder (the AB) and at least one other Axis I clinical syndrome or Axis II personality disorder (the MD), all as diagnosed by the DSMI I I - R (American Psychiatric Association, 1987), then dual diagnosis is common. High levels of comorbidity are supported by the findings of the largest and most comprehensive study on the prevalence of alcohol, drug, and mental disorders, the Epidemiologic Catchment Area (ECA) study (Regier et al., 1990). The ECA study found that among those who have ever had a mental disorder, 29% also have had a substance abuse disorder sometime in their lifetime. The lifetime rate of substance dependence or abuse was 31% for (those who ever had) dysthymia, 27% for unipolar depression, 36% for panic disorder, 33% for obsessive-compulsive disorder, 84 % for antisocial personality disorder, 47 % for schizophrenia, and 56% for bipolar disorder. Although these lifetime percentages overestimate the point prevalence of comorbidity in the general population, the study also examined comorbidity in the treatment population. It found that "almost 20% of individuals with mental disorders who come to specialty treatment settings will have a current diagnosis of substance abuse disorder" (Regier et al., 1990, p. 2517). When considered from the direction of alcohol or drug use, rates are even higher. Fifty-five percent of patients receiving treatment for an alcohol problem, and 64% of patients receiving treatment for a drug problem, also have a mental disorder. Other studies have found broadly similar rates of comorbidity (Galanter & Castaneda, 1991; Hasin, Grant & Endicott, 1988; Mirin, Weiss, Michael & Griffin, 1988). In summary, about one fifth of the patients in M D treatment also have a current AB disorder, and more than half of the patients in AB treatment also have a current MD. Dual Diagnosis Is Difficult to Assess and Difficult to Treat Virtually every dual diagnosis paper comments on the difficulty of assessment and treatment. Diagnostic and etiologic uncertainty, highly variable course, compliance problems, premature termination, and relatively poor treatment outcome are repeatedly mentioned (Carey, 1991; Drake & Wallach, 1989; Lehman, Herron, Schwartz, & Myers, 1993; Levine & Harper, 1991; Miller & Gold, 1991a; Stoffelmayr, Benishek, Humphreys, Lee, & Mavis, 1989; Wolfe & Sorensen, 1989). Dual Diagnosis Findings Are Primarily Descriptive and Conceptual There has been insufficient experimental work for many firm conclusions

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to be drawn about the etiology or treatment of dual diagnosis, or about comorbidity in general (Brown & Barlow, 1992; Clarkin & Kendall, 1992). The available experimental work on dual diagnosis can be classified into two small groups of studies, based on subject recruitment. The first group has approached subject recruitment by identifying AB among patients with major M D (primarily schizophrenia or major affective disorder), and then tested the efficacy of various interventions for these dual diagnosis patients. Published studies in this group have thus far yielded no or minor positive findings (Bond, McDonel, Miller, & Pensec, 1991; Carey, Carey, & Meisler, 1990; Lehman et al., 1993). The second group has approached subject recruitment by identifying M D among patients being treated for opiate dependence. These studies have found evidence that added (cognitive-behavioral or supportive-expressive) psychotherapy may result in better outcome than achieved by drug counseling and methadone maintenance alone, particularly among patients with moderate to high severity of M D (Woody, McLellan, Luborsky, & O'Brien, 1990; Woody, McLellan, & O'Brien, 1990). These studies also found significant outcome differences between individual psychotherapists. A strong predictor of outcome was the patient's rating of the helping relationship. There is a significant body of non-experimental literature addressing specific dual diagnosis combinations, the treatment of dual diagnosis in special populations, and dual diagnosis treatment in specific settings. Most of this literature is less than two decades old, and easily searchable by computer. Many Causal Relationships Between AB and M D Are Possible There are at least five possible causal relationships between AB and MD: (1) Independent disorders occur concurrently and do not affect one another, (2) one disorder (the primary) causes the other (the secondary), (3) one disorder increases the risk of developing the other, (4) one disorder modifies the course of the other, and (5) the disorders are unrelated except to the extent that indi o viduals with two or more disorders are more likely to seek professional help (Sederer, 1990). There appears to be some evidence of each of these possibilities, and each should be considered in the individual case. The primary versus secondary causal relationship appears to have received the most attention. Some have emphasized AB causing M D (Bean-Bayog, 1986; Miller & Gold, 1991b; O'Connor, Berry, Morrison, & Brown, 1992), and others have emphasized AB as symptomatic of underlying psychological maladjustment (Bell & Khantzian, 1991; Kaufman, 1989).

Practice Guidelines These guidelines assume a psychotherapist who treats MD, not AB. The psychotherapist is assumed to screen out and refer cases in which the AB is the

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stated reason for seeking treatment, or the AB is obvious enough that it needs to be one of the immediate focuses of treatment (e.g., a husband seeks help for controlling his temper, because he and his wife fight every night, after he consumes two to three bottles of wine). The referral would normally occur in the initial phone call or session. The patients who remain have less obvious AB, or will not accept a referral. The patient is assumed to continue in treatment until the psychotherapist or patient sees no benefit in continuing (the presenting problems may or may not be resolved), or referral is accepted. Look for Multiple AB's in Every Patient AB can be defined as the repeated use of a substance, in order to experience subjectively perceived benefits, even though an objective assessment of the substance use would conclude that the resulting harm outweighed the benefits. The AB is preceded by the experience of craving (also described as "an urge"), or the AB prevents the experience of craving. In both cases the individual tends to experience a reduction in the capacity to think objectively, and a sense of being "out of control" with respect to engaging in the AB. An individual's AB can be globally rated according to the degree of absolute objective harm it causes. The subjectively perceived benefits of the AB may change over time (e.g., regular drinking begins in order "to get high" but continues years later in order to prevent withdrawal), and are often very short term. If the "harm outweighs the benefits" component of this definition is removed, positive AB (Glasser, 1976) could also be subsumed under it. An advantage of defining AB to include both positive and negative aspects is that the successful reduction of negative AB almost invariably includes increasing positive AB (Marlatt, 1985b; Abrams & Niaura, 1987). This way of framing the change is helpful to some patients. M y clinical experience suggests that virtually all patients will exhibit several past or present negative AB's, some of which may also be severe enough to meet diagnostic criteria. This observation merely broadens an already well established observation, that if a patient has one diagnosable substance abuse disorder, then others are likely (Schuckit, 1989). It is a rare human being whose habits are uniformly positive. The identification of negative AB's at various levels of severity is useful for setting up opportunities for self-modeling ("I quit smoking, how did I do it?"); enhancing self-efficacy ("I could learn to control my pot-smoking as well as I already control my drinking. I do drink too much but it's not nearly as bad as the pot"); and providing material for illustrating central treatment concepts ("You had a strong urge to smoke, but you noticed that after five minutes of conversation the urge was gone"). Identification of positive AB will also be useful in treatment planning, by identifying resources the patient has available. This practice guideline can typically be accomplished by asking about common substance AB's on routine intake forms, and in the initial interview ("Do you

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have any habits that it would be good to change, or that others want you to change?"), with follow-up questions as appropriate. One should also follow up, during the course of treatment, on any other mentions of possible AB's ("I've noticed that several times you've mentioned having a few beers after work:'). Once the behavior is a topic of discussion, it can be evaluated as described below. Although more extensive screening measures might identify some AB sooner, these measures would be employed at the risk of annoying many patients, and could still fail to identify AB in the patient who did not yet trust the psychotherapist enough to reveal it. Having some AB (and other problems) go undetected by initial assessment is rooted in the fact that the requirements of a thorough assessment include time and trust. Evaluate AB's to the Extent of Your Expertise Although a comprehensive evaluation (Donovan & Marlatt, 1989; Tarter, Ott, & Mezzich, 1991) ofa diagnosable AB would require experience diagnosing and treating that AB, a thorough evaluation is not necessarily needed. Evaluation has been found to function as a significant treatment intervention (Miller & Rollnick, 1991). Assuming that no evaluation is utterly complete, then all evaluation is in varying degrees incomplete. Even an incomplete evaluation can be a significant aid to natural recovery. Such an evaluation can also help build the patient's motivation for specialty evaluation and treatment. The Alcohol Dependence Scale (ADS) is a measure of alcohol problems that could be completed by the patient, or used as a basis for a structured interview (Skinner & Allen, 1982). The Drug Abuse Screening Test (DAST-20), a measure of drug problems, could similarly be employed (Skinner, 1982). Both are inexpensive instruments available from the Addiction Research Foundation, Toronto, Ontario, Canada, at 1-800-661-1111. These, and other measures specific to the AB being assessed, are recommended for use after a behavior has been raised as a topic of discussion. In this way the measure can be employed in a collaborative framework ("I think we need to know more about your drinking. I'd like to go through this set of questions with you. Does that sound OK?"). Conduct a cost-benefit analysis. A cost-benefit analysis of the AB is both an assessment and a motivational intervention (Horvath, 1993). The cost-benefit analysis appears to be most effective if it is begun by focusing on the benefits of the AB. Resistance to a discussion about the AB is much less likely if the question is "what do you like about drinking?", rather than "what problems has drinking caused?" Only after a thorough discussion of the benefits is the shift made to costs: We've been talking about what you like about drinking. If you think we have pretty much covered that topic, then I'm also curious about whether there are some things you don't like about drinking: whether it's caused any problems for

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you. As you know, just about everything in life has pros and cons to it, and I'm curious now about the cons. The patient who perceives that the benefits of drinking have been understood is much more likely to volunteer information about the costs. The benefits of the AB can be rated on various dimensions of coping. On the assumption that the AB is a coping method, then the specific areas in which coping assistance occurs include coping with negative emotions, enhancing positive emotions, preventing withdrawal or physical pain, eliminating craving, providing a response to social pressure to engage in the addictive behavior or to other interpersonal conflict, and providing a normative activity or sense of normality (Annis, 1986; Marlatt, 1985c). The types and levels of coping assistance vary with the severity of the AB. However, even without remembering the specific coping areas identified by research, the psychotherapist can gain significant understanding simply by pursuing the question "how does this AB help the patient cope?" In general, the benefits of the AB tend to be experienced immediately. The costs of the AB tend to be experienced over a longer period, and can be rated on various dimensions of impact on the patient's life. These dimensions include the physical/medical, interpersonal, financial, vocational, legal, familial, sexual, recreational, psychological/emotional, behavioral, and cognitive, as well as the level of contradiction with the patient's core beliefs. These core beliefs may be described in moral, ethical, religious, spiritual, or philosophical terms. Although the use of the term spiritual may be reminiscent of Alcoholics Anonymous, C B T has from its inception been interested in the patient's core beliefs (Beck, Rush, Shaw, & Emery, 1979). Orford (1986) has suggested that moral or spiritual change is a significant element in recovery from AB. One simple method for beginning to address this issue is to ask about the patient's reaction to any uncharacteristic behaviors arising from the AB. The cost-benefit analysis is completed by inquiring about the conclusions the patient draws after comparing the costs and benefits identified. Given the patient we are assuming, these conclusions will probably indicate little motivation to take immediate action about the AB. Evaluate the history of readinessfor change. Five stages of readiness for change of an AB (or other problem) have been identified (DiClemente, 1993; Prochaska & DiClemente, 1982; Prochaska, DiClemente, & Norcross, 1992). The five stages (considered from the AB perspective) are (1) precontemplation (I am not interested in changing), (2) contemplation (Maybe I should cut back or stop this), (3) preparation (I'm taking small steps now, and plan major action soon), (4) action (I am abstaining/moderating [for one to 180 days]), and (5) maintenance (I've accomplished my goal [for over 180 days] but need to make sure I don't relapse). Motivational interventions (e.g., thorough assessment and feedback, cost-

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benefit analysis) are more appropriate in the earlier stages. Action (i.e., abstinence or moderation training) and relapse prevention interventions are more appropriate in the later stages. Many patients appear to spiral through the stages, perhaps needing multiple action attempts before achieving long-term maintenance (e.g., the patient may relapse from action to contemplation, progress to maintenance, relapse to preparation, progress to maintenance, etc.). A mismatch between the attempted intervention and the stage of change is relatively wasted effort (e.g., attempting to teach skills for coping with craving, which is a task of the action stage, to a patient in the precontemplation stage). The recent history and the patient's responses to direct questions about readiness--perhaps in the context of describing these five stages--may often provide a sufficient assessment of the current stage. The patient we are assuming is likely to be in one of the first three stages. Include a Problem List in the Initial Assessment A comprehensive list of the patient's problems (including all significant negative A.B), even if some of these problems cannot be addressed in psychotherapy, is essential to adequate assessment and treatment (Persons, 1989). The problem list may include items which the psychotherapist believes are worth monitoring, even if the patient is in the precontemplation stage regarding change: This is not an issue you are interested in addressing right now, but I am concerned that it may complicate our other work. I want to put it on the problem list, so we don't lose sight of it. This is like your family doctor making a note about a mole you have: it's not something you want to take care of right now, but we need to check on it from time to time. Some private practice psychotherapists may not have client file folders that facilitate the use of a problem list. Stationers sell heavy cardboard file folders with six sections, each with metal tabs (for two-hole punched papers). These folders allow for the problem list, treatment plan, most recent homework assignment, and any other crucial documents (e.g., managed care authorization forms) to be at the top of individual sections, and readily accessible. Mutually Negotiate a Treatment Plan A treatment plan is a list of actions to be taken, in a certain order, on the basis of a rationale, in order to reduce specific problems. The accomplishment of any significant phase of the plan, or any significant difficulty in accomplishing a phase, are opportunities for reconsidering the plan. The plan must be acceptable to the patient in order to be successful. The rationale will include assumptions, based on the best available evidence, about causal relationships between

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the problems specified, and about how treatment itself will affect these problems and their relationships. To the extent the patient is willing, the best available evidence will include observation over time, an accurate and complete history, information from significant others, psychological assessment, and medical evaluation. We have assumed a patient (1) whose AB is interfering with an established treatment plan (or seems likely to interfere with a proposed treatment plan) for M D and (2) who has refused referral to specialized AB treatment but still wants treatment (i.e., is in the action stage) for MD. Having initially evaluated the AB, constructed a problem list, and completed other evaluation as clinically indicated, the following questions then arise: Will the patient accept referral to non-disease model treatment? W h e n the suggestion of referral is made, the patient will likely assume that the specialty AB treatment program is disease model oriented. M a n y individuals believe that disease model treatment is the only AB treatment available in the United States. If the patient assumes that treatment will involve attending groups, accepting a label of alcoholic or addict, making public confessions, letting go to a higher power, and so forth, refusal to accept the referral may change if a reputable C B T or other non-disease model program can be identified. Will the patient agree to temporary abstinence or moderation? Even if the patient refuses referral, agreement to abstinence or moderation of use, for a specified period of time, may still occur if it is clearly requested. Although m a n y may not be able to follow through entirely, the result may nevertheless be an overall reduction in use, which will facilitate the M D treatment. T h e period of time recommended should be consistent with the requirements of the M D treatment. Abrupt cessation of a sedative or alcohol can have serious and possibly lethal consequences, and medical evaluation should be firmly recommended prior to this course of action. Despite such a recommendation, many patients have experience monitoring their own withdrawal and will elect not to obtain medical consultation.

Will the patient agree to make readinessfor change of the A B the focus of treatment? The contemplation stage patient may be willing to defer treating the presenting problem to examine the AB in more detail. Is a trial of M D treatment feasible? Once the patient has been informed of the relative chances of success of the M D treatment, given the presence of the AB, the responsibility for the course taken belongs to the patient. The following discussion, which in its elaboration might require an entire session, illustrates this option: As we have discussed, I believe that you are experiencing what professionals call depression. Because you have had symptoms of depression for over 3 years, it is difficult to know how long treatment might be needed, and how successful it could be. I can say that, based on m y past ex-

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perience in treating depression, if you attend sessions regularly for as long as I recommend, complete homework assignments, and tell me what you are really thinking and feeling, even if it is about me or our sessions, then your chances of feeling substantially improved are m u c h better than 50%. However, what I've just said applies to someone who is not also drinking and smoking pot. I don't really know how successful treatment can be with these chemicals in your system. Some individuals begin their use of alcohol or pot not depressed, and become depressed apparently because of these chemicals. So, you could be doing everything right in therapy and still not be getting better just because of the alcohol and pot. O n the other hand, I do not know for sure that you cannot get better and still drink and smoke. All I can really say is that it seems likely that alcohol and pot will make the job harder, but I can't even say how much harder. If getting over the depression is the highest priority for you, then abstaining from alcohol and pot is probably your best move. However, if they are also important to you, and you don't want to focus on them right now, we could try treating your depression for an agreed on amount of time, and then look at how far you have come. A typical fear about this plan is that if little progress has been made by the end of the trial, the psychotherapist will feel under pressure for not having performed adequately. If despite this outcome the patient is still motivated for treatment, this is an opportunity to clarify the patient's fundamental reasons for seeking treatment, which probably have not been sufficiently understood. If the patient is still motivated for treatment, then some significant benefit is being perceived. Understanding this perceived benefit will facilitate the development of a realistic treatment plan. A M D treatment trial may not be feasible because of financial considerations. The care manager, insuror, parent, employer, or other third party may not pay for M D treatment until various conditions are met, such as that AB treatment be completed and abstinence be monitored. Will the patient agree to simultaneous A B and M D treatment? There are m a n y interventions for AB that non-specialists can at least partially provide. These include conducting a cost-benefit analysis; assigning the patient to monitor use or the frequency, intensity, and duration of cravings; developing alternative activities; activity scheduling; identifying and testing irrational thoughts (in particular, those associated with cravings, or the perceived costs and benefits of the AB); suggesting a brief trial of abstinence or moderation; encouraging support group attendance; and having family information gathering or psychoeducation ses-

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sions. These interventions can be interwoven, on the basis of clinical judgement, with the treatment of the MD. Beck, Wright, N e w m a n and Liese (1993) present detailed descriptions of these and other AB interventions. If the patient elects to continue in treatment, even having been informed that the psychotherapist is not a specialist in treating AB, then this choice can be viewed as a type of successive approximation. If the purpose of treatment is to aid natural recovery (which is based on the patient's assumed innate capacity for self-healing and further adaptation), then even the non-specialist's interventions may prove successful. If they are not, the patient will have experienced more negative consequences of the AB ("it's serious enough that my therapist couldn't help me") for consideration during the next contemplation stage or course of treatment. A c o m m o n fear a m o n g general practice psychotherapists is that the AB patient eventually will say "you have no idea what I am talking about, so how can you help me?" T h e irony is that this is the message the psychotherapist has been attempting without success to communicate: "Yes, I am not a specialist in this area, and now we both agree that you need one." A referral might now be accepted. T h e term dual diagnosis does not appear to exist in medicine (Weiss, Mirin, & Frances, 1992). Medical patients often have multiple disorders, but treatment for each proceeds unless there is a significant risk of one treatment interfering with the other. In these cases the empirical literature when available, and clinical judgement as necessary, indicate the proper treatment course. To the extent that an AB is a method for the patient to cope with an MD, then a reduction in the AB may result in an exacerbation of the symptoms of the MD. Assuming that both the patient (via informed consent) and the psychotherapist (via technical expertise) are prepared for this possibility, there is no reason not to proceed if the patient consents. Exposure to feelings, thoughts, and images is often an essential step in the treatment of MD. Unless the patient's M D is viewed as untreatable, the psychotherapist should attempt to moderate exposure to the extent possible, and manage the effects of exposure as necessary. In these cases it is assumed that the psychotherapist has substantial expertise in treating the M D and its possibly severe symptoms (e.g., suicidal ideation, dissociative episode, abreaction), and has rapid access to other providers and levels of care. Proceeding by small steps in both the treatment of AB and M D is one route to minimizing symptomatic exacerbations. The primary prediction of this paper is that the general practice psychotherapist is already able to help AB patients, without exposing them to unwarranted risk ofiatrogenic harm. The psychotherapist can actively focus on the AB using previously learned psychotherapeutic methods, such as those mentioned above. T h e patient will be better served than if given a referral that is not accepted. T h e overall treatment strategy is to work on problems the patient is willing to work on, for as long as the patient is motivated to work. T h e psychotherapist does not relinquish the option to remind the patient of other problems that are

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in need of attention, or to keep looking for opportunities to work on them. If (even relatively minor) progress on the presenting problems occurs, the patient may be willing to address the other problems, perhaps in specialty treatment if needed. Adopting this strategy entails taking a long-term view of the case, and recognizing that if resolution of the entire problem list ever occurs, the psychotherapist is likely to be involved only briefly and intermittently during the entire resolution process. Monitor Your Own Attitude Toward AB and Its Treatment If the psychotherapist signals indirectly that certain topics are not of interest, the patient may well act accordingly. Any responsible psychotherapist would discuss the patient's perceived employment stresses, even if the psychotherapist had no experience with that type of employment. Basic interviewing skills (especially empathy), a willingness to inquire regarding the unfamiliar, and sufficient time will allow for at least an overview understanding of the patient's experience. The AB patient, like any other human being, is attempting to maximize pleasures and satisfactions, and minimize pain, all as understood by the patient. Every new patient presents a variation of the same attempt. Rather than viewing the patient as having a disease or condition that makes the patient different, it is more productive to search for an understanding of how the AB is being chosen as an optimal way of coping, and how to develop new coping methods. It is instructive for the psychotherapist to recognize personal AB, positive and negative, however subtle. This recognition enhances the capacity for empathy. A simple way to begin is to self-monitor for cravings to consume various substances. Cravings are experienced as an increase in tension (however slight), and the expectation that the tension will go away if the craving is acted on. To what extent do I just act on the craving, perhaps without considering it at all, even if acting thus is not in my long-term interest? To what extent do I rationalize this act? To what extent do I quickly stop thinking about this whole sequence, as not really being a problem? The disease model of AB has been so well established in the United States that it may be difficult for some psychotherapists to think in new ways about AB. However, for an M D patie~lt the psychotherapist is likely to empathize and collaborate (rather than confront), to understand (rather than label), to empower (rather than emphasize powerlessness), to help identify choices (rather than insist on one course of action), and to appeal to experience and reason (rather than faith). Importing traditional psychotherapeutic attitudes to the treatment of AB may require practice. For the psychotherapist who succeeds in this task, the magnitude of the distinction between treating M D and AB may diminish.

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