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Psychotherapy with dual diagnosis patients: Working with denial
Journal of Substance Abuse Treatment, Vol. 10, pp. 499-504, 1993 Printed in the USA. All rights reserved.
0740-5472193 $6.00 + .OO Copyright 0 1993 Pergamon Press Ltd.
ARTICLE
Psychotherapy With Dual Diagnosis Patients: Working With Denial MICHAEL
LEVY,
PhD
Harvard Medical School, Cambridge, Massachusetts
Abstract - The author discusses a strategy of working with chronically impaired dual diagnosispa-
tients who are in denial of their substance abuse problems. It is argued that due to a number of unique features among such patients, directly confronting denial and insisting on abstinence will not be effective for many of these patients. Instead, it LFsuggested thot patients’ continued substance use should be tolerated although at the same time be made a focus of treatment. Techniques are offered which can be utilized to broach the denial of this challenging patient population. Typs of patients not suitable for this approach are also discussed. Keywords-dual
diagnosis; psychotherapy; denial; substance abuse; alcoholism.
A TYPICAL PROBLEM
when working with dual diagnosis patients (patients who experience both a psychiatric illness and a substance abuse/dependence problem) is denial of their substance abuse problems or poor motivation for treatment. So frequently, these patients do not want to acknowledge their difficulty with substance use nor do they want to become drug free. At the same time, acknowledgment of a substance abuse problem is the first step to one’s overall recovery. A patient must first admit substance abuse is a problem before a willingness to strive for abstinence occurs. Quite definitely, dual diagnosed patients will need to become abstinent if they are going to improve their lives. Their increased psychiatric fragilities as compared to nondual diagnosed patients render them even less able to deal with the psychoactive effects of nonprescribed chemicals. In addition, the interaction between nonprescribed and prescribed drugs can lead to a number ofidifficulties including the potentiation of prescribed medication, a decreased efficacy of prescribed medication, and potentially dangerous synergistic effects (Johnson & Ellison, 1989). Clinicians, thus, are left in a quandary about how to treat dual diagnosis patients who do not recognize their substance use as a problem. For example, if pa-
tients refuse to see their substance use as a difficulty, should they continue to be seen? Or even if a substance abuse problem is admitted, should a clinician continue to work with a patient even if substance abuse continues? And how does one broach the denial of a dual diagnosis patient? Does one confront the patient regarding the substance abuse problem and insist on abstinence? Or rather does one attempt to engage the patient into treatment despite active substance abuse? An important, if not critical, component of the treatment of an active substance abuser is the establishment of abstinence. Treatment for a substance abuse problem generally suggests to confront patients’ denial and to help patients to see the destructive nature of their substance abuse. Nate (1987) writes: “For the physician to try to establish a therapeutic relationship may prove futile with the patient who has no ‘problem’, needs ‘no help’, and is generally defiant or blocked by denial” (p. 117). He further writes: “The defiant, denying patient may require and be best served by an approach in which confrontation of behavior is put forth in an effective manner” (p. 118). If denial is successfully broached, patients will then be able to acknowledge the destructiveness of their substance abuse and can then enter into a program of recovery. This model of substance abuse treatment has naturally been carried over into work with the psychiatric patient who also has a chemical abuse problem. Concerning conducting psychotherapy with dual diagno-
Requests for reprints should be addressed to Michael Levy, PLD, 2 Elm Square, Andover, MA 01810.
499
500
sis patients, Kaufman (1989) writes that a patient’s commitment to abstinence must be a condition of the therapeutic contract. Frequently as well, if substance abuse continues, treatment may be terminated, although the patient will be invited back when motivated for treatment (Kaufman, 1989). For a number of reasons, I do not see this approach as being particularly helpful for a majority of dual diagnosis patients, particularly those patients who have debilitating chronic mental illnesses such as schizophrenia, schizoaffective illness, and severe personality disorders in conjunction with their substance abuse problems. While this approach might be useful for some, for many confronting denial and insisting on abstinence will fall on empty ears. Such confrontation could also result in a psychotic decompensation in a vulnerable individual (Brown, Ridgely, Pepper, Levine, & Ryglewicz, 1989). In this paper, I will first discuss why I think that confronting denial will not be effective for many chronically ill psychiatric patients who struggle with a chemical abuse problem. I will then present an alternative model for dealing with the unmotivated dual diagnosis patient which I have found to be of considerable usefulness. This discussion may also be helpful for the treatment of many nonpsychiatrically impaired substance abusers who remain in denial in addition to those dual diagnosis patients who have less severe psychiatric difficulties. BARRIERS TO TREATMENT ENGAGEMENT The Therapeutic Alliance Patients experiencing a substance abuse problem compounded by a major mental illness or a severe personality disorder are generally hesitant to form relationships with treatment providers (Fariello & Scheidt, 1989). Many of these patients tend to be paranoid, mistrustful of others, and previous relationships with others have been marked by pain, hurt, and rejection. As a result, it may take considerable time for the mentally ill substance abuser to engage into treatment, to form a solid therapeutic alliance with a therapist, and to follow the recommended treatment. To insist on abstinence before a therapeutic relationship has been developed is bound to fail. In essence, such an approach places the cart before the horse. Instead, one must first work on building trust and the therapeutic alliance. Only after the patient has been successfully engaged into treatment can one expect the patient to listen to a recommendation of abstinence from drugs. Consequently, an initial focus on establishing sobriety may not be beneficial. The more important focus of treatment should be on developing a trusting relationship with the patient and a good working therapeutic alliance. As Ridgely et al. (1987) has noted:
M. Levy
“Denial of substance abuse problems is particularly difficult to manage without the prior establishment of a trusting, therapeutic relationship . . . While abstinence is clearly the goal, it is not a precondition to beginning the treatment process” (p. 19). Identity Concerns The overall identity of a patient with serious psychiatric difficulties tends to be quite fragmented. Who they are and what they want to be doing are probably not well established. Deficits in ego functioning and self-care exist, as do difficulties around the development of the self (Arieti, 1974; Sullivan, 1953). Their ability to establish healthy, positive relationships with others, an important way in which one defines oneself, is also deficient. One way such a dual diagnosis patient can define who he or she is is through the use of chemicals. Using drugs can give one a sense of identity and purpose. Chemical use also provides a means through which the patient can form relationships with others. This is also true for many substance abusers who do not have a concurrent mental illness. Drug use can provide a patient with a peer group to relate with and to belong to. Defining oneself as a drug user can also help to shore up a weakened identity. While the effects of chemicals can cause ego fragmentation and self traumatization, a life-style centered around chemical use has its positive functions for the patient. As Khantzian (1975) has noted, chemicals have important adaptive mechanisms for patients and help patients to relieve their troubling affective states. Chemical use can also be a way in which dual diagnosis patients deny that they have a mental illness. I have worked with several patients who have used chemicals, particularly the hallucinogens, as a way to deny their own mental illnesses. Hallucinations and disordered thinking can be blamed on the chemical use rather than as being seen as having a separate, autonomous existence. Consequently, for the chronically impaired dual diagnosis patient in particular, the idea of stopping the use of chemicals is even more overwhelming than it is for a patient with a substance abuse problem without a concomitant mental illness. Without the use of chemicals, only an extremely poorly formed identity is left. While nondual diagnosis patients must also frequently face this, for dual diagnosis patients, the absence of a coherent sense of self is typically even more striking. Or even worse, for perhaps the first time, dual diagnosed patients may have to face the fact that even without chemical use, their overall integration and functioning in the world is quite impaired. To face all of these issues at once, which stopping chemical use will precipitate, especially before a solid relationship has been formed with a therapist, may be more than
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a patient can tolerate. Indeed it may not be appropriate to expect this of the patient, at least not at the outset of treatment. Without chemical use, there is literally nothing to fall back on. Why Get Sober?
Generally, individuals suffering from a substance abuse problem finally stop using chemicals because of the deleterious consequences of their substance use. Due to substance use, the person experiences financial, legal, vocational, psychological, social/interpersonal, and/or physical problems. A person might get fired from his or her job, a spouse decides to separate, debts begin to mount, a mortgage cannot be paid, or perhaps the person is arrested. Despite a wish to continue to use chemicals, the person makes the decision to no longer use chemicals because the individual does not want to suffer the consequences of the drug use. Without consequences related to drug use, a person would never consider stopping. For a number of reasons, consequences related to drug use are frequently less obvious among chronically impaired dual diagnosis patients. Or at a minimum, it may be more difficult to get the patient to see the consequences of the drug use. For example, let us suppose that a patient we see is homeless and lives in a shelter, does not work, and has no close interpersonal relationships. The person does not get violent when under the influence so legal difficulties do not occur, and SSI/SSDI provides enough income to purchase the drugs. Why should this individual stop using chemicals? How does it hurt the person? On the surface, the consequences are not readily apparent. When someone is at the bottom of the socioeconomic ladder with no wish to ever get employment, drug use may not lead to losses and clear consequences. The social connections which may motivate an individual to get sober may also be lacking (Evans & Sullivan, 1990). In fact, in many cases, drug use may not be causing the person obvious problems. The effects are more subtle and may have more to do with preventing the person from getting what is wanted rather than causing outright difficulties. And generally it will take time for patients to begin to entertain goals for themselves, to have some hope for a better life, or to develop the wish to be someone different. Once this occurs (if it occurs), only then will patients consider stopping chemical use if the use of chemical comes to be seen as something preventing them from attaining their goals. For example, perhaps a patient eventually develops a desire to have some relationships with others and begins to see how chemical use prevents this from happening. Or maybe a patient decides that he or she no longer wants to live in a shelter, and that the only way to get into a residential program will be to become ab-
stinent. It will take time for patients to both develop goals for themselves and to see how drug use affects them. Thus, to initially focus on the patient’s need to get sober will have no relevance. Quite commonly, patients wonder about why they should get sober. What is in it for them? With no goals or reasons to stop using, it literally makes no sense to even consider stopping. Treatment must initially focus on developing a therapeutic relationship and a safe place for patients to begin to look at themselves. Once this occurs and the patient begins to share some of his or her pain, concerns, tragedies, and what they would like to be different, only then may we be able to show the patient how chemicals may be making it all worse and how stopping chemical use may be the first step towards realizing their goals. The patient must have something to lose or conversely something to gain before abstinence will be considered. Until a good reason to stop chemical use is established, the notion of stopping simply carries no purpose. Indeed, preliminary work with patients should focus on helping them to discover some meaningful treatment goals. Once treatment goals have been developed, an exploration of whether or not chemical use will prevent them from attaining their goals can then begin. WORKING
WITH DENIAL
The approach advocated here does not confront denial directly although at the outset of treatment, the therapist should impart the message that drug use appears to be a problem and something that needs to be addressed. Initially, a direct, nonjudgemental, and noncritical questioning about drug use is undertaken. Questions about how often drugs are used and what types of drugs are taken are asked. If asked in a caring, empathic manner, rather than hearing “I never use drugs”, more commonly the patient will report that while drugs are used it is not a problem. The latter is what needs to be acknowledged in order to begin true therapeutic work. If the patient does not acknowledge any drug use, the first task will be to create an atmosphere where the patient can trust enough to share his or her drug use. Provided that the patient reports some drug use, the next phase of treatment will be determined by the degree of the patient’s denial of the substance abuse problem. As the focus of this paper is on the dual diagnosis patient who is in denial, I will center the discussion on this and will not talk about conducting clinical work with the patient who is ready to strive for abstinence. Many people have discussed how to help people become abstinent once the problem is acknowledged (Brown, 1985; Gallant, 1987; Nate, 1987; Kaufman, 1989; Zimberg, 1985). Before beginning a discussion of treatment interventions, several caveats must first be mentioned. As has been stated, the approach advocated here does not
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confront denial directly. Patients are accepted “where they are,” and in fact, patients’ use of substances is tolerated. All patients, though, are given a clear message at the outset of treatment that their substance use seems to be a problem which needs to be addressed. Thus, while patients are accepted as they are, simultaneously they know that their clinician sees their substance use as a problem. For some patients, however, the extent or quality of their (poly)substance abuse or dependence and the self-destructive potential of it may be so great that to not insist on abstinence would clearly be contraindicated. Such patients need containment, safety, and a clear message that their substance use must stop if they are going to get better. In addition, effective psychotherapy could not occur with such patients if they continued to use. Along similar lines, patients who have a history of overdose or suicide attempts while under the influence of drugs or those who experience current suicidal ideation would also not be suitable for this approach. Psychopharmacological interventions for these patients must also be carefully reviewed. While these patients may need psychotropic medication, interactions between prescribed and nonprescribed chemicals can potentially be dangerous. Certain medications can fairly safely be administered while others must be avoided. Each case must be individually evaluated taking into account the needs of the patient and what nonprescribed chemicals the patient uses (see Jaffe, Kranzler, & Ciraulo, 1992 for a thorough discussion of psychopharmacology with this patient population). In what follows, I have broken down therapeutic strategies which can be used to help patients to eventually see how substance abuse affects them and how it fits into their lives into four general categories. These are techniques which can be utilized throughout the therapeutic process based upon the status of the patient and the content of the therapeutic hour. These approaches are not mutually exclusive, but can be combined and used together. Helping the Patient to Find a Treatment
Goal
As previously stated, patients affected by a substance abuse problem need to have a compelling reason to stop using if they are going to try abstaining from chemicals. Frequently, dual diagnosis patients have little reason to stop using substances. They have no specific current goals nor do they have objectives for the future. The hope of finding a good job or buying a home does not exist. Chemical use does not affect relationships with others as they are isolated and internally preoccupied. The thought of establishing a caring relationship with another may also be beyond their imagination. As a result, before one thinks about
the goal of abstinence for the patient, the therapist must first find out what the patient wants for him or herself. There must be a goal of treatment stated by thepatient. Frequently with a dual diagnosis patient, the goal of treatment is assumed to be abstinence which really is the therapist’s goal. The formation of a treatment goal may take time to develop and certainly can and frequently does change throughout the therapeutic process. However, this needs to be the first task of treatment. Without this, treatment can become an empty, meaningless endeavor with both therapist and patient questioning what they are doing. While the need for a patient to have a treatment goal is obvious, this is important to state as so often with dual diagnosis patients, the goal of abstinence is assumed without the patient fully concurring that this is the goal of treatment. We must not forget that although an active substance abuse problem seems to us to be an appropriate focus of treatment, the patient may not share our view. And until the patientfirst has an idea of what he or she wants, abstinence as a treatment goal has no relevance. Consequently, our work must first entail developing a relationship with our patients and helping them to discover what they want different in their lives. At times, we need to “forget” about our patients’ substance abuse problems and focus instead on helping them to discover what they would like to change or have different in their lives. The Relationship Between Substance Use and the Treatment Goal Once there is a stated treatment goal, the next task of
treatment is to intermittently inquire about or point out the possible relationship between substance use and the treatment goal. This can occur if the patient has difficulty attaining the stated treatment goal and the reason for this remains unclear. For example, let us assume that after several months of therapy, a patient decides that he or she would like to attempt some part-time work. After several more months of not finding employment, of repeated excuses as to why success has not been attained (e.g., got up late, didn’t feel good, saw some friends), and the therapist’s unsuccessful exploration of possible anxiety about working and avoidance of seeking employment, it could prove beneficial for the therapist to ask in a nonjudgemental, offhanded, inquiring way whether the patient’s use of chemicals could play a role in the problem. This may help the patient to see how substance use may affect him or her. At a minimum, it plants the thought and forces the patient to think about and consider this idea. In general, if substance use does play an important role in our patients’ difficulties and makes it impossible for them to achieve their goals, patients’ denial may be broached by the
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therapist repeatedly having them ponder the idea that substance abuse might be playing a pivotal role in their inability to attain their treatment goals. In fact, if substance use is a problem, the use of chemicals will undoubtedly play an important role in our patient’s difficulties.
Be an Observing Ego
There will be other times throughout the course of treatment when patients describe using chemicals and having some difficulties, but the connection between the substance use and their problems remains outside of their awareness or unacknowledged. For example, a patient may report getting into a fight with someone they live with. As this is explored, the patient reports that the other person was giving him or her a hard time and it was all the other person’s fault. It also becomes evident that the patient had been smoking some marijuana, which makes the patient more selfreferential and paranoid. At some point in the hour, the therapist could suggest the possibility that the patient’s use of marijuana might have been a factor in the difficulty and share with the patient the rationale behind this thinking. Whether or not the patient agrees, the clinician is at least suggesting this idea for the patient to consider. And, of course, throughout the therapeutic process, there will be many opportunities for the therapist to be the patient’s observing ego. By continually being mindful of the patient’s drug abuse problem and when obvious, suggesting the possible role of drug use in the problems the patient is experiencing, denial of the substance abuse problem can be broached.
Drawing a Link Between Drug Use and Psychopathology
Working with dual diagnosis patients demands that the therapist be attuned to both the patient’s emotional suffering and the patient’s substance use. The therapist must never forget that chemicals are habitually utilized by these patients to deal with their emotional concerns and with any conflict or problem which arises. Consequently, when a patient shares some dysphoria, while empathically listening, affirming the patient’s pain, and attempting to help the patient to better understand what is happening and what to do about it, the therapist can also inquire about whether it is at these times when chemicals may be used. In one and the same intervention, the patient’s emotional distress in fully acknowledged and the defense the patient typically utilizes to cope with it is suggested. This intervention can be most effective when the patient is in touch with his or her pain for it is at these times when the patient
may be less defended and more able to acknowledge how substance use comes into play. Fariello and Scheidt (1989) also discuss how it can be beneficial for the therapist to help dual diagnosis patients to understand the relationship between their chemical addiction, their emotional difficulties, and the problems they are experiencing. Affirming the intense pain the patient experiences and sharing how chemical use is not simply a problem but also a solution can enable a patient to, in turn, acknowledge the extent of substance use. The therapist can also share how while chemical use does truly help in the short run, in the long run it only worsens everything. I once worked with a paranoid schizophrenic man who had a concurrent amphetamine abuse problem. After using amphetamines, he would consistently become more agitated, paranoid, and isolated. For years, the reasons for his substance abuse were not clear to either himself or to me. In addition, the extent of the problem was also minimized. After years of working together, in one session he spoke about his incredible sense of isolation and alienation from others. He also discussed how he had never been with a woman and he wondered if he ever would be. He spoke about what a difficult time he had in meeting women, not knowing how to act around them. It was at this point when I inquired about the possible relationship between his substance abuse and this difficulty- perhaps he used substances to cope with this pain. It was at this moment when a light bulb lit up for him. He reported that while this was true to some degree, the more important reason was that when he first took the amphetamines, he would lose his self-consciousness, he would become more social, and he felt that he could better connect with others. I then shared with him how I could understand his use of the substance, that it truly did help. However, in the long run, it only hurt him as afterwards he would feel disorganized for days. He acknowledged this and I then told him that perhaps we could work together to help him to feel less selfconscious without drugs, which greatly appealed to him. This led to a deepening of our work together, a breakthrough in his denial, and to him eventually achieving sobriety. SUMMARY
Chronically impaired dual diagnosis patients, as a result of their more fragile identities, their greater resistance to attaching to treatment, and the less obvious reasons they may have to attain sobriety, may be less responsive to a therapist’s direct confrontation of their denial of their substance abuse problems. In place of confrontation, other interventions aimed to broach the denial of such patients are offered. These include: 1. Helping the patient to find a treatment goal.
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2. Enabling the patient to see the relationship between substance abuse and the treatment goal. 3. Functioning as the patient’s observing ego. 4. Drawing the link between substance abuse and the patient’s suffering. These interventions meet patients where they are and may help treating clinicians to establish good working alliances with their patients. Continued substance abuse, while accepted, should remain in the therapeutic field and should be brought to the attention of the patient when appropriate. In this manner, patients may come to see their substance use as a problem and as something to address in their treatment. Therapists’ anxieties about their patients’ continued use of substances must be tolerated. Despite continued substance use, it can be beneficial to develop a relationship with a dual diagnosis patient (Kofoed, Kania, Walsh, & Atkinson, 1986). Therapists must sit with their patients and allow patients to discover for themselves how their chemical use interferes in their lives. This must occur before patients will be able to consider the idea that their substance abuse is a problem and something that must be stopped. REFERENCES Arieti, S. (1974). The Interpretution ofSchizophrenia (2nd ed.). New York: Basic Books. Brown, S. (1985). Treating the alcoholic, a developmental model of recovery. New York: Wiley. Brown, V.B., Ridgely, MS., Pepper, B., Levine, IS., & Ryglewicz, H. (1989). The dual crisis: Mental illness and substance abuse: Present and future directions. American Psychologist, 44, 565-569.
Evans, K., & Sullivan, J.M. (1990). Dual diagnosis. Counseling the mentally ill substance abuser. New York: The Guilford Press. Fariello, D., & Scheidt, S. (1989). Clinical case management of the dually diagnosed patient. Hospital & Community Psychiatry, 40, 1065-1067. Gallant, D.M. (1987). Alcoholism. A guide to diagnosis, intervention, and treatment. New York: W.W. Norton. Jaffe, J.H., Kranzler, H.R., & Ciraulo, D.A. (1992). Drugs used in treatment of alcoholism. In J.H. Mendelson & N.K. Mello (Eds.), Medicaldiagnosis in treatment of alcoholism. New York: McGraw-Hill. Johnson, M., & Ellison, J.M. (1989). Interactions of alcohol, street drugs, and prescribed medications. In J.M. Ellison (Ed.), The Psychotherapist’s Guide to Pharmacotherapy. Chicago: Year Book Medical Publishers. Kofoed, M.D., Kania, J., Walsh, T., &Atkinson, R.M. (1986). Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. American Journal of Psychiatry, 143, 867-872. Nate, E.P. (1987). The treatment of alcoholism. New York: Brunner/Mazel. Kaufman, E. (1989). The psychotherapy of dually diagnosed patients. Journal of Substance Abuse Treatment, 6, 9-18. Khantzian, E.J. (1975). Self selection and progression in drug dependence. American Journal of Psychotherapy, 36, 19-22. Ridgely, M.S., Osher, EC., Goldman, H.H., Talbott, J.A., & the Task Force on Chronic Mentally Ill Young Adults, The University of Maryland at Baltimore. (1987, December). Executive summaty: Chronic mentally ill adults with substance abuse problems: A review of research, treatment, and training issues. Submitted to Alcohol, Drug Abuse and Mental Health Administration, U.S. Department of Health and Human Services, and Department of Health and Mental Hygiene State of Maryland. Sullivan, H.S. (1953). The interpersonal theory ofpsychiatry. New York: W.W. Norton. Zimberg, S. (1985). Principles of alcoholism psychotherapy. In S. Zimberg, J. Wallace, & S. Brown (Eds.), Practical approaches to alcoholism psychotherapy (2nd ed.). New York: Plenum.
0740-5472193 $6.00 + .OO Copyright 0 1993 Pergamon Press Ltd.
ARTICLE
Psychotherapy With Dual Diagnosis Patients: Working With Denial MICHAEL
LEVY,
PhD
Harvard Medical School, Cambridge, Massachusetts
Abstract - The author discusses a strategy of working with chronically impaired dual diagnosispa-
tients who are in denial of their substance abuse problems. It is argued that due to a number of unique features among such patients, directly confronting denial and insisting on abstinence will not be effective for many of these patients. Instead, it LFsuggested thot patients’ continued substance use should be tolerated although at the same time be made a focus of treatment. Techniques are offered which can be utilized to broach the denial of this challenging patient population. Typs of patients not suitable for this approach are also discussed. Keywords-dual
diagnosis; psychotherapy; denial; substance abuse; alcoholism.
A TYPICAL PROBLEM
when working with dual diagnosis patients (patients who experience both a psychiatric illness and a substance abuse/dependence problem) is denial of their substance abuse problems or poor motivation for treatment. So frequently, these patients do not want to acknowledge their difficulty with substance use nor do they want to become drug free. At the same time, acknowledgment of a substance abuse problem is the first step to one’s overall recovery. A patient must first admit substance abuse is a problem before a willingness to strive for abstinence occurs. Quite definitely, dual diagnosed patients will need to become abstinent if they are going to improve their lives. Their increased psychiatric fragilities as compared to nondual diagnosed patients render them even less able to deal with the psychoactive effects of nonprescribed chemicals. In addition, the interaction between nonprescribed and prescribed drugs can lead to a number ofidifficulties including the potentiation of prescribed medication, a decreased efficacy of prescribed medication, and potentially dangerous synergistic effects (Johnson & Ellison, 1989). Clinicians, thus, are left in a quandary about how to treat dual diagnosis patients who do not recognize their substance use as a problem. For example, if pa-
tients refuse to see their substance use as a difficulty, should they continue to be seen? Or even if a substance abuse problem is admitted, should a clinician continue to work with a patient even if substance abuse continues? And how does one broach the denial of a dual diagnosis patient? Does one confront the patient regarding the substance abuse problem and insist on abstinence? Or rather does one attempt to engage the patient into treatment despite active substance abuse? An important, if not critical, component of the treatment of an active substance abuser is the establishment of abstinence. Treatment for a substance abuse problem generally suggests to confront patients’ denial and to help patients to see the destructive nature of their substance abuse. Nate (1987) writes: “For the physician to try to establish a therapeutic relationship may prove futile with the patient who has no ‘problem’, needs ‘no help’, and is generally defiant or blocked by denial” (p. 117). He further writes: “The defiant, denying patient may require and be best served by an approach in which confrontation of behavior is put forth in an effective manner” (p. 118). If denial is successfully broached, patients will then be able to acknowledge the destructiveness of their substance abuse and can then enter into a program of recovery. This model of substance abuse treatment has naturally been carried over into work with the psychiatric patient who also has a chemical abuse problem. Concerning conducting psychotherapy with dual diagno-
Requests for reprints should be addressed to Michael Levy, PLD, 2 Elm Square, Andover, MA 01810.
499
500
sis patients, Kaufman (1989) writes that a patient’s commitment to abstinence must be a condition of the therapeutic contract. Frequently as well, if substance abuse continues, treatment may be terminated, although the patient will be invited back when motivated for treatment (Kaufman, 1989). For a number of reasons, I do not see this approach as being particularly helpful for a majority of dual diagnosis patients, particularly those patients who have debilitating chronic mental illnesses such as schizophrenia, schizoaffective illness, and severe personality disorders in conjunction with their substance abuse problems. While this approach might be useful for some, for many confronting denial and insisting on abstinence will fall on empty ears. Such confrontation could also result in a psychotic decompensation in a vulnerable individual (Brown, Ridgely, Pepper, Levine, & Ryglewicz, 1989). In this paper, I will first discuss why I think that confronting denial will not be effective for many chronically ill psychiatric patients who struggle with a chemical abuse problem. I will then present an alternative model for dealing with the unmotivated dual diagnosis patient which I have found to be of considerable usefulness. This discussion may also be helpful for the treatment of many nonpsychiatrically impaired substance abusers who remain in denial in addition to those dual diagnosis patients who have less severe psychiatric difficulties. BARRIERS TO TREATMENT ENGAGEMENT The Therapeutic Alliance Patients experiencing a substance abuse problem compounded by a major mental illness or a severe personality disorder are generally hesitant to form relationships with treatment providers (Fariello & Scheidt, 1989). Many of these patients tend to be paranoid, mistrustful of others, and previous relationships with others have been marked by pain, hurt, and rejection. As a result, it may take considerable time for the mentally ill substance abuser to engage into treatment, to form a solid therapeutic alliance with a therapist, and to follow the recommended treatment. To insist on abstinence before a therapeutic relationship has been developed is bound to fail. In essence, such an approach places the cart before the horse. Instead, one must first work on building trust and the therapeutic alliance. Only after the patient has been successfully engaged into treatment can one expect the patient to listen to a recommendation of abstinence from drugs. Consequently, an initial focus on establishing sobriety may not be beneficial. The more important focus of treatment should be on developing a trusting relationship with the patient and a good working therapeutic alliance. As Ridgely et al. (1987) has noted:
M. Levy
“Denial of substance abuse problems is particularly difficult to manage without the prior establishment of a trusting, therapeutic relationship . . . While abstinence is clearly the goal, it is not a precondition to beginning the treatment process” (p. 19). Identity Concerns The overall identity of a patient with serious psychiatric difficulties tends to be quite fragmented. Who they are and what they want to be doing are probably not well established. Deficits in ego functioning and self-care exist, as do difficulties around the development of the self (Arieti, 1974; Sullivan, 1953). Their ability to establish healthy, positive relationships with others, an important way in which one defines oneself, is also deficient. One way such a dual diagnosis patient can define who he or she is is through the use of chemicals. Using drugs can give one a sense of identity and purpose. Chemical use also provides a means through which the patient can form relationships with others. This is also true for many substance abusers who do not have a concurrent mental illness. Drug use can provide a patient with a peer group to relate with and to belong to. Defining oneself as a drug user can also help to shore up a weakened identity. While the effects of chemicals can cause ego fragmentation and self traumatization, a life-style centered around chemical use has its positive functions for the patient. As Khantzian (1975) has noted, chemicals have important adaptive mechanisms for patients and help patients to relieve their troubling affective states. Chemical use can also be a way in which dual diagnosis patients deny that they have a mental illness. I have worked with several patients who have used chemicals, particularly the hallucinogens, as a way to deny their own mental illnesses. Hallucinations and disordered thinking can be blamed on the chemical use rather than as being seen as having a separate, autonomous existence. Consequently, for the chronically impaired dual diagnosis patient in particular, the idea of stopping the use of chemicals is even more overwhelming than it is for a patient with a substance abuse problem without a concomitant mental illness. Without the use of chemicals, only an extremely poorly formed identity is left. While nondual diagnosis patients must also frequently face this, for dual diagnosis patients, the absence of a coherent sense of self is typically even more striking. Or even worse, for perhaps the first time, dual diagnosed patients may have to face the fact that even without chemical use, their overall integration and functioning in the world is quite impaired. To face all of these issues at once, which stopping chemical use will precipitate, especially before a solid relationship has been formed with a therapist, may be more than
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a patient can tolerate. Indeed it may not be appropriate to expect this of the patient, at least not at the outset of treatment. Without chemical use, there is literally nothing to fall back on. Why Get Sober?
Generally, individuals suffering from a substance abuse problem finally stop using chemicals because of the deleterious consequences of their substance use. Due to substance use, the person experiences financial, legal, vocational, psychological, social/interpersonal, and/or physical problems. A person might get fired from his or her job, a spouse decides to separate, debts begin to mount, a mortgage cannot be paid, or perhaps the person is arrested. Despite a wish to continue to use chemicals, the person makes the decision to no longer use chemicals because the individual does not want to suffer the consequences of the drug use. Without consequences related to drug use, a person would never consider stopping. For a number of reasons, consequences related to drug use are frequently less obvious among chronically impaired dual diagnosis patients. Or at a minimum, it may be more difficult to get the patient to see the consequences of the drug use. For example, let us suppose that a patient we see is homeless and lives in a shelter, does not work, and has no close interpersonal relationships. The person does not get violent when under the influence so legal difficulties do not occur, and SSI/SSDI provides enough income to purchase the drugs. Why should this individual stop using chemicals? How does it hurt the person? On the surface, the consequences are not readily apparent. When someone is at the bottom of the socioeconomic ladder with no wish to ever get employment, drug use may not lead to losses and clear consequences. The social connections which may motivate an individual to get sober may also be lacking (Evans & Sullivan, 1990). In fact, in many cases, drug use may not be causing the person obvious problems. The effects are more subtle and may have more to do with preventing the person from getting what is wanted rather than causing outright difficulties. And generally it will take time for patients to begin to entertain goals for themselves, to have some hope for a better life, or to develop the wish to be someone different. Once this occurs (if it occurs), only then will patients consider stopping chemical use if the use of chemical comes to be seen as something preventing them from attaining their goals. For example, perhaps a patient eventually develops a desire to have some relationships with others and begins to see how chemical use prevents this from happening. Or maybe a patient decides that he or she no longer wants to live in a shelter, and that the only way to get into a residential program will be to become ab-
stinent. It will take time for patients to both develop goals for themselves and to see how drug use affects them. Thus, to initially focus on the patient’s need to get sober will have no relevance. Quite commonly, patients wonder about why they should get sober. What is in it for them? With no goals or reasons to stop using, it literally makes no sense to even consider stopping. Treatment must initially focus on developing a therapeutic relationship and a safe place for patients to begin to look at themselves. Once this occurs and the patient begins to share some of his or her pain, concerns, tragedies, and what they would like to be different, only then may we be able to show the patient how chemicals may be making it all worse and how stopping chemical use may be the first step towards realizing their goals. The patient must have something to lose or conversely something to gain before abstinence will be considered. Until a good reason to stop chemical use is established, the notion of stopping simply carries no purpose. Indeed, preliminary work with patients should focus on helping them to discover some meaningful treatment goals. Once treatment goals have been developed, an exploration of whether or not chemical use will prevent them from attaining their goals can then begin. WORKING
WITH DENIAL
The approach advocated here does not confront denial directly although at the outset of treatment, the therapist should impart the message that drug use appears to be a problem and something that needs to be addressed. Initially, a direct, nonjudgemental, and noncritical questioning about drug use is undertaken. Questions about how often drugs are used and what types of drugs are taken are asked. If asked in a caring, empathic manner, rather than hearing “I never use drugs”, more commonly the patient will report that while drugs are used it is not a problem. The latter is what needs to be acknowledged in order to begin true therapeutic work. If the patient does not acknowledge any drug use, the first task will be to create an atmosphere where the patient can trust enough to share his or her drug use. Provided that the patient reports some drug use, the next phase of treatment will be determined by the degree of the patient’s denial of the substance abuse problem. As the focus of this paper is on the dual diagnosis patient who is in denial, I will center the discussion on this and will not talk about conducting clinical work with the patient who is ready to strive for abstinence. Many people have discussed how to help people become abstinent once the problem is acknowledged (Brown, 1985; Gallant, 1987; Nate, 1987; Kaufman, 1989; Zimberg, 1985). Before beginning a discussion of treatment interventions, several caveats must first be mentioned. As has been stated, the approach advocated here does not
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confront denial directly. Patients are accepted “where they are,” and in fact, patients’ use of substances is tolerated. All patients, though, are given a clear message at the outset of treatment that their substance use seems to be a problem which needs to be addressed. Thus, while patients are accepted as they are, simultaneously they know that their clinician sees their substance use as a problem. For some patients, however, the extent or quality of their (poly)substance abuse or dependence and the self-destructive potential of it may be so great that to not insist on abstinence would clearly be contraindicated. Such patients need containment, safety, and a clear message that their substance use must stop if they are going to get better. In addition, effective psychotherapy could not occur with such patients if they continued to use. Along similar lines, patients who have a history of overdose or suicide attempts while under the influence of drugs or those who experience current suicidal ideation would also not be suitable for this approach. Psychopharmacological interventions for these patients must also be carefully reviewed. While these patients may need psychotropic medication, interactions between prescribed and nonprescribed chemicals can potentially be dangerous. Certain medications can fairly safely be administered while others must be avoided. Each case must be individually evaluated taking into account the needs of the patient and what nonprescribed chemicals the patient uses (see Jaffe, Kranzler, & Ciraulo, 1992 for a thorough discussion of psychopharmacology with this patient population). In what follows, I have broken down therapeutic strategies which can be used to help patients to eventually see how substance abuse affects them and how it fits into their lives into four general categories. These are techniques which can be utilized throughout the therapeutic process based upon the status of the patient and the content of the therapeutic hour. These approaches are not mutually exclusive, but can be combined and used together. Helping the Patient to Find a Treatment
Goal
As previously stated, patients affected by a substance abuse problem need to have a compelling reason to stop using if they are going to try abstaining from chemicals. Frequently, dual diagnosis patients have little reason to stop using substances. They have no specific current goals nor do they have objectives for the future. The hope of finding a good job or buying a home does not exist. Chemical use does not affect relationships with others as they are isolated and internally preoccupied. The thought of establishing a caring relationship with another may also be beyond their imagination. As a result, before one thinks about
the goal of abstinence for the patient, the therapist must first find out what the patient wants for him or herself. There must be a goal of treatment stated by thepatient. Frequently with a dual diagnosis patient, the goal of treatment is assumed to be abstinence which really is the therapist’s goal. The formation of a treatment goal may take time to develop and certainly can and frequently does change throughout the therapeutic process. However, this needs to be the first task of treatment. Without this, treatment can become an empty, meaningless endeavor with both therapist and patient questioning what they are doing. While the need for a patient to have a treatment goal is obvious, this is important to state as so often with dual diagnosis patients, the goal of abstinence is assumed without the patient fully concurring that this is the goal of treatment. We must not forget that although an active substance abuse problem seems to us to be an appropriate focus of treatment, the patient may not share our view. And until the patientfirst has an idea of what he or she wants, abstinence as a treatment goal has no relevance. Consequently, our work must first entail developing a relationship with our patients and helping them to discover what they want different in their lives. At times, we need to “forget” about our patients’ substance abuse problems and focus instead on helping them to discover what they would like to change or have different in their lives. The Relationship Between Substance Use and the Treatment Goal Once there is a stated treatment goal, the next task of
treatment is to intermittently inquire about or point out the possible relationship between substance use and the treatment goal. This can occur if the patient has difficulty attaining the stated treatment goal and the reason for this remains unclear. For example, let us assume that after several months of therapy, a patient decides that he or she would like to attempt some part-time work. After several more months of not finding employment, of repeated excuses as to why success has not been attained (e.g., got up late, didn’t feel good, saw some friends), and the therapist’s unsuccessful exploration of possible anxiety about working and avoidance of seeking employment, it could prove beneficial for the therapist to ask in a nonjudgemental, offhanded, inquiring way whether the patient’s use of chemicals could play a role in the problem. This may help the patient to see how substance use may affect him or her. At a minimum, it plants the thought and forces the patient to think about and consider this idea. In general, if substance use does play an important role in our patients’ difficulties and makes it impossible for them to achieve their goals, patients’ denial may be broached by the
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therapist repeatedly having them ponder the idea that substance abuse might be playing a pivotal role in their inability to attain their treatment goals. In fact, if substance use is a problem, the use of chemicals will undoubtedly play an important role in our patient’s difficulties.
Be an Observing Ego
There will be other times throughout the course of treatment when patients describe using chemicals and having some difficulties, but the connection between the substance use and their problems remains outside of their awareness or unacknowledged. For example, a patient may report getting into a fight with someone they live with. As this is explored, the patient reports that the other person was giving him or her a hard time and it was all the other person’s fault. It also becomes evident that the patient had been smoking some marijuana, which makes the patient more selfreferential and paranoid. At some point in the hour, the therapist could suggest the possibility that the patient’s use of marijuana might have been a factor in the difficulty and share with the patient the rationale behind this thinking. Whether or not the patient agrees, the clinician is at least suggesting this idea for the patient to consider. And, of course, throughout the therapeutic process, there will be many opportunities for the therapist to be the patient’s observing ego. By continually being mindful of the patient’s drug abuse problem and when obvious, suggesting the possible role of drug use in the problems the patient is experiencing, denial of the substance abuse problem can be broached.
Drawing a Link Between Drug Use and Psychopathology
Working with dual diagnosis patients demands that the therapist be attuned to both the patient’s emotional suffering and the patient’s substance use. The therapist must never forget that chemicals are habitually utilized by these patients to deal with their emotional concerns and with any conflict or problem which arises. Consequently, when a patient shares some dysphoria, while empathically listening, affirming the patient’s pain, and attempting to help the patient to better understand what is happening and what to do about it, the therapist can also inquire about whether it is at these times when chemicals may be used. In one and the same intervention, the patient’s emotional distress in fully acknowledged and the defense the patient typically utilizes to cope with it is suggested. This intervention can be most effective when the patient is in touch with his or her pain for it is at these times when the patient
may be less defended and more able to acknowledge how substance use comes into play. Fariello and Scheidt (1989) also discuss how it can be beneficial for the therapist to help dual diagnosis patients to understand the relationship between their chemical addiction, their emotional difficulties, and the problems they are experiencing. Affirming the intense pain the patient experiences and sharing how chemical use is not simply a problem but also a solution can enable a patient to, in turn, acknowledge the extent of substance use. The therapist can also share how while chemical use does truly help in the short run, in the long run it only worsens everything. I once worked with a paranoid schizophrenic man who had a concurrent amphetamine abuse problem. After using amphetamines, he would consistently become more agitated, paranoid, and isolated. For years, the reasons for his substance abuse were not clear to either himself or to me. In addition, the extent of the problem was also minimized. After years of working together, in one session he spoke about his incredible sense of isolation and alienation from others. He also discussed how he had never been with a woman and he wondered if he ever would be. He spoke about what a difficult time he had in meeting women, not knowing how to act around them. It was at this point when I inquired about the possible relationship between his substance abuse and this difficulty- perhaps he used substances to cope with this pain. It was at this moment when a light bulb lit up for him. He reported that while this was true to some degree, the more important reason was that when he first took the amphetamines, he would lose his self-consciousness, he would become more social, and he felt that he could better connect with others. I then shared with him how I could understand his use of the substance, that it truly did help. However, in the long run, it only hurt him as afterwards he would feel disorganized for days. He acknowledged this and I then told him that perhaps we could work together to help him to feel less selfconscious without drugs, which greatly appealed to him. This led to a deepening of our work together, a breakthrough in his denial, and to him eventually achieving sobriety. SUMMARY
Chronically impaired dual diagnosis patients, as a result of their more fragile identities, their greater resistance to attaching to treatment, and the less obvious reasons they may have to attain sobriety, may be less responsive to a therapist’s direct confrontation of their denial of their substance abuse problems. In place of confrontation, other interventions aimed to broach the denial of such patients are offered. These include: 1. Helping the patient to find a treatment goal.
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2. Enabling the patient to see the relationship between substance abuse and the treatment goal. 3. Functioning as the patient’s observing ego. 4. Drawing the link between substance abuse and the patient’s suffering. These interventions meet patients where they are and may help treating clinicians to establish good working alliances with their patients. Continued substance abuse, while accepted, should remain in the therapeutic field and should be brought to the attention of the patient when appropriate. In this manner, patients may come to see their substance use as a problem and as something to address in their treatment. Therapists’ anxieties about their patients’ continued use of substances must be tolerated. Despite continued substance use, it can be beneficial to develop a relationship with a dual diagnosis patient (Kofoed, Kania, Walsh, & Atkinson, 1986). Therapists must sit with their patients and allow patients to discover for themselves how their chemical use interferes in their lives. This must occur before patients will be able to consider the idea that their substance abuse is a problem and something that must be stopped. REFERENCES Arieti, S. (1974). The Interpretution ofSchizophrenia (2nd ed.). New York: Basic Books. Brown, S. (1985). Treating the alcoholic, a developmental model of recovery. New York: Wiley. Brown, V.B., Ridgely, MS., Pepper, B., Levine, IS., & Ryglewicz, H. (1989). The dual crisis: Mental illness and substance abuse: Present and future directions. American Psychologist, 44, 565-569.
Evans, K., & Sullivan, J.M. (1990). Dual diagnosis. Counseling the mentally ill substance abuser. New York: The Guilford Press. Fariello, D., & Scheidt, S. (1989). Clinical case management of the dually diagnosed patient. Hospital & Community Psychiatry, 40, 1065-1067. Gallant, D.M. (1987). Alcoholism. A guide to diagnosis, intervention, and treatment. New York: W.W. Norton. Jaffe, J.H., Kranzler, H.R., & Ciraulo, D.A. (1992). Drugs used in treatment of alcoholism. In J.H. Mendelson & N.K. Mello (Eds.), Medicaldiagnosis in treatment of alcoholism. New York: McGraw-Hill. Johnson, M., & Ellison, J.M. (1989). Interactions of alcohol, street drugs, and prescribed medications. In J.M. Ellison (Ed.), The Psychotherapist’s Guide to Pharmacotherapy. Chicago: Year Book Medical Publishers. Kofoed, M.D., Kania, J., Walsh, T., &Atkinson, R.M. (1986). Outpatient treatment of patients with substance abuse and coexisting psychiatric disorders. American Journal of Psychiatry, 143, 867-872. Nate, E.P. (1987). The treatment of alcoholism. New York: Brunner/Mazel. Kaufman, E. (1989). The psychotherapy of dually diagnosed patients. Journal of Substance Abuse Treatment, 6, 9-18. Khantzian, E.J. (1975). Self selection and progression in drug dependence. American Journal of Psychotherapy, 36, 19-22. Ridgely, M.S., Osher, EC., Goldman, H.H., Talbott, J.A., & the Task Force on Chronic Mentally Ill Young Adults, The University of Maryland at Baltimore. (1987, December). Executive summaty: Chronic mentally ill adults with substance abuse problems: A review of research, treatment, and training issues. Submitted to Alcohol, Drug Abuse and Mental Health Administration, U.S. Department of Health and Human Services, and Department of Health and Mental Hygiene State of Maryland. Sullivan, H.S. (1953). The interpersonal theory ofpsychiatry. New York: W.W. Norton. Zimberg, S. (1985). Principles of alcoholism psychotherapy. In S. Zimberg, J. Wallace, & S. Brown (Eds.), Practical approaches to alcoholism psychotherapy (2nd ed.). New York: Plenum.