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Treatment of dual diagnosis patients: A relapse prevention group approach
Journal of Substance Abuse Treatment, Vol. Printed in the USA. All rightsreserved.
9, pp.
305-309,
1992 Copyright
0
0740-5472/92 $5.00 + .OO 1992 Pergamon Press Ltd.
ARTICLE
Treatment of Dual Diagnosis Patients: A Relapse Prevention Group Approach RAJENDRA NIGAM, MD, RICHARD SCHOTTENFELD, MD, AND THOMAS R. KOSTEN, MD Substance
Abuse Treatment Unit, Department of Psychiatry, Yale University School of Medicine
Abstract - The authors describe the successful use of an adjunctive group psychotherapy for substance-abusing patients with major psychiatric disorders (bipolar, schizophrenia, schizoaffective, psychotic depression, and atypical psychosis). The group utilizes a psychoeducational approach that focuses on substance abuse causes and consequences, principles of recovery, and relapse prevention strategies. Eight patients with prolonged histories of abuse of cocaine, alcohol, marijuana, or other drugs were enrolled in this weekly group treatment at a community mental health center drug treatmentprogram, while continuing in treatment with their current case manager or primary therapist. Six of the eight patients achievedperiods of stable abstinence, documented by self-report, urine toxicology screens, continued group attendance, and improved social functioning. Case examples are utilized to illustrate the group process.
Keywords-Schizophrenia;
drug abuse; group therapy;
INTRODUCTION SUBSTANCE ABUSE OR DEPENDENCE is a problem for 20% to 50% of young, chronically mentally ill patients and leads to considerable excess disability (Drake & Wallach, 1989; Negrete, Werner, Knopp, Douglas, & Smith, 1986; Richard, Liskow, & Perry, 1985; Mueser, Yarnold, & Bellack, 1990; Barbee, Clark, Crapanzo, Heintz, & Kehoe, 1989). Patients with schizophrenia and other psychotic disorders are particularly likely to abuse stimulants, hallucinogens, marijuana, and alcohol (Mueser et al., 1990; Schnier, Siris, 1988). Compared to the non-substance-abusing psychotic patient, the psychotic substance abuser suffers more frequent and severe relapse, experiences higher rates of rehospitalization, and is considerably more difficult to engage in treatment (Drake & Wallach, 1989; Hall, Popkin, Devaul, & Stickney, 1977; Schwartz 8z Goldfinger, 1981). While substance abuse is often diagnosed in routine clinical practice, the failure to detect it contributes to
Supported by NIDA grants P50-DA04060, KOZ-DA0112 (TRK), 5T32-DA07238 and R18-DAO6190. Requests for reprints should be addressed to Thomas R. Kosten, MD,Substance Abuse Research Center, 27 Sylvan Avenue, New Haven, CT 06519.
psychoeducational;
dual diagnosis.
the worst outcome (Hall et al., 1977). Despite increased recognition of the importance of diagnosis and treatment of substance abuse in the severely mentally ill, there has been little discussion in the literature of successful treatment approaches for this population. Siris (1990) describes potential pharmacologic treatment approaches, all of which await systematic evaluation. Several investigators have pointed to the difficulty in integrating psychosocial approaches suitable to patients with schizophrenia (supportive, nurturing, nonconfrontational approaches designed to minimize anxiety and understand symptoms) with traditional drug abuse treatments (limit-setting, confrontational, and holding the abuser responsible for his or her behavior) (Kleber, 1988; Hellerstein & Meehan, 1986). There is also considerable controversy about whether dually diagnosed patients are best treated in psychiatric or substance abuse programs or whether conjoint treatment can be successful. Two groups of investigators have described outpatient group treatment approaches adapted for this population. Kofoed, Kania, Walsh, and Atkinson (1986) described an outpatient program for alcohol-abusing veterans with severe psychiatric disorders (schizophrenia, bipolar disorder, personality disorder, anxiety disorder, organic mental disorder). Of the 32 patients enrolled in their program,
306
R. Nigam et al.
14 also abused other drugs. The program included a weekly support group, routine prescription of disulfiram, monitoring of drug and alcohol use, and encouragement to attend Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings. Adjunctive individual or family therapy, day treatment, and relapse prevention or assertiveness training groups were available as adjunctive treatments. Drop-out rates from the program were quite high, with two-thirds dropping out within 2 months and 22% (7/32) remaining in treatment for one year or more. None of the drug-abusing patients remained in treatment more than 6 months. Hellerstein and Meehan (1987) utilized a weekly group format that focused on a psychoeducational approach, including engagement in the group, interpersonal skill development, and problem solving. Half of their initial 10 patients remained in treatment for one year (7 for 6 months), and there was a nonsignificant decrease in the average number of days hospitalized annually during the 3 years prior to entry into group treatment compared to the one year after entry (24.6 f 21.4 days/ year to 7.8 +_9.9 days/year). No data was presented describing changes in substance use following entry into the group. Because few descriptions of successful outpatient treatments for patients with severe coexisting psychiatric and substance use disorders are available, we are describing a successful group therapy approach in a community mental health center. The group psychotherapy focused on substance abuse recovery and was adjunctive to individual case management for these patients with major psychiatric disorders. Case examples are used to illustrate the treatment approach. METHOD Subjects
Since August 1989 we have conducted an outpatient dual diagnosis group with 3 male and 5 female patients whose ages ranged from 21 to 45 years (mean age = 3 1 years). They had individual case managers and received appropriate psychotropics, as described in the table. Procedure
The psychoeducational sessions were held once a week for one hour. The patients were encouraged to discuss their daily activities, including use of leisure time, and eventually to share their feelings. Group sessions also covered new or interesting social activities such as church fairs, games, dinners, and dances. Patients often made plans to participate together in these activities. Relapse and slips were handled in a nonjudgmental, supportive manner, and did not lead to automatic termination from the group. The patients were encouraged to discuss the details leading to these slips or
binges, such as when and where they occurred, what events lead to them, and whether they were alone or with others during the period of use. Thus the precipitants of relapse, including emotional upsets or feeling lonely, anxious, irritable, depressed, as well as slighted by others, and the situations leading to drug use were discussed in detail. Afterwards suggestions were made by the group on how to handle these situations in the future. Role playing by the patients was encouraged to allow acquisition of skills. Therapy was not limited only to the group sessions. The group therapists maintained an active liaison with other care providers, case managers, and vocational rehabilitation counselors. Formal social interactions between therapists and patients occurred on occasions when coffee and donuts were brought to the group. The patients discussed their absences and explained the reasons to the group. Unplanned absences were confronted by the group. Outcome
Outcome measures included patients’ attendance, retention in treatment, and abstinence. Drug abuse slips and binges were self-reported, and patients were monitored with weekly urine toxicologies. RESULTS Two patients (#4 & #5) dropped out of the program. They frequently abused marijuana and cocaine, and their urines were almost always positive. Two patients (#l and #2) attended more than 90% of all sessions and were invariably punctual. They achieved abstinence lasting 12 and 10 months, respectively, as verified by urine toxicologies. The other four patients attended approximately 80% of sessions, and all of their urines were negative for illicit drugs. Although all of her urines were negative for cocaine, patient #6 reported two relapses during 10 months of treatment. She continued to attend the group regularly in spite of these relapses. Case Histories
Case #I -Lapse to Drug Use. Patient #6 (ML) binged IV cocaine 9 months after entering the group. She reported this to the group at the next meeting and explained that one of her drug-abusing friends visited her and offered her cocaine. She told the group that she was feeling low on that day and was alone in her apartment without anything to do. She felt that she could not resist getting high, although she tried to resist at first. The group listened to her very carefully and sympathetically. They discussed and developed a relapse prevention strategy for this patient, as follows: 1. Don’t allow your drug using friends to visit you and say “no” boldly.
307
Dual Diagnosis-Relapse Prevention TABLE 1 Clinical Characteristics and Outcomes for Psychotic Substance Abusers Demographics
Psychiatric
Abused Drugs (maximum use) Cocaine
ID No. Sex Race Age 1 2 3 4
M F F F
W W W 6
30 27 21 34
Diagnosis
Meds
Bipolar Bipolar Psychosis NOS Schizo-Paranoid
LVprolixin LVtrilafon trilafon mellaril prolixin decanots LVprolixin activan LVprolixin restoril DMVChlorpromazine
5
M
W
27
6
F
W
27SA
7
M
B
37
Schizo
w
45
Depress psychotic
8
F
SA-manic
naltrexone
gmlwk 2.5 2.0 7
yr
ozlwk
Marijuana
yr jtslwk
yr
Other
16 NA 0 Heroin 7 Amphet
Months Positive Months Urines Abstain Rx 12 10 7
0 0 0
12 13 7
NA
6
? all
0
NA
6
few
0
10 4 3
30 ND 12
8 14 8
14 0 72
14
4
ND
20
7
19
<1
14
ND
14
2
9
1
4
54
13
49
13
Heroin
10
3.5
1.5
45
16
0
16
Heroin
6
0
0
0
10
10
2
0
Disconnect yourself completely from drug abusers. 3. Call one of the group therapists or any other member of the group when you are feeling low. When she encountered the same situation the following week, she was able to say “no” and control herself. In the next session she happily told the group that this strategy worked for her.
2.
Case #2-Problems
Alcohol
Outcomes
Patient #l missed two group sessions 6 months after entering the group. Upon return to the next sessions, the group asked about the reason for his absence. The patient reported that he had gone to the beach for the past 2 weeks. Members of the group confronted this behavior and scolded the patient for missing the group sessions. After these incidents, his unplanned absences stopped. With Attendance.
Case #3-Addition of New Members. The group developed intimacy and cohesiveness, but remained welcoming to new members. New members were treated empathetically and respectfully by the group. Although the group was interested in knowing the details about a new member, in order to understand him or her better, group members refrained from pressing with too many questions right away. Patient #8 joined the group 6 months after the group formed. She was depressed due to the recent deaths of her two teenaged children. She was quite guarded initially and stated that she disliked coming to the group. She felt the group was not the right place for her and did not want to continue. Following the encouragement of group members to stay within the group, she continued, and in the following sessions she began to talk more freely and discuss her
coke 2
10 6 ?l or5
feelings, including liking the group. Although she required inpatient hospitalization several weeks later due to severe depression, she continued to attend the group weekly while hospitalized. She has successfully maintained abstinence for 2 months since her hospital discharge. DISCUSSION While treatment approaches for the substance-abusing patient with a major psychiatric disorder are still evolving, it has been suggested that a unified team approach under one roof is superior to concurrent treatment in more than one setting. These cases suggest successful treatment, as measured by abstinence rates and decreased hospitalization, can be accomplished in a primary substance abuse treatment setting for the dually diagnosed with concurrent treatment by other providers. We believe that the following ingredients are needed for a successful group approach for the “dual diagnosis” patient. 1. Active therapists who start a small number of patients in the group (e.g., 3 or 4). 2. Good communication with any primary care providers who are not group co-therapists. 3. Abstinence should be a goal rather than a criterion for admission to or remaining in the group. 4. Clear rules regarding use of substances or drugs when patients attend group, including not attending if intoxicated. 5. An open discussion in the group of any lapses to drug abuse, 6. Emphasis on education and skill building.
308
7. Encouragement to use 1Zstep groups (i.e., AA, NA) beyond these psychotherapy groups.
R. Nigam et al.
nosed patient is particularly crucial, since they are often exploited by other drug users and dealers who are not psychiatrically impaired.
(1) Active Therapists
Since patients with chronic psychiatric disorders generally have poor social skills, it is important that therapists maintain an active stance, including making suggestions and actively containing the group process. Therapists need to model constructive confrontation for these patients so that the group process does not become chaotic and destructive. Since it is often difficult to engage these patients in group therapy, therapists must be willing to start with a small number (3-4 patients) and add to the core group, as these early patients are taught appropriate group behavior. Patient interactions will often be focused on the therapist at first, but ultimately patient-to-patient interactions can be fostered. (2) Good Communication
Good communication with primary therapists, case managers, and other care givers cannot be emphasized enough in an integrated approach. Successful treatment depends on patients revealing to their substance abuse group plans to stop their psychotropic medications, and on the group using its peer pressure to maintain medication compliance. Stopping antipsychotic medications is often a result of a major stressor related to a substance abuse lifestyle, and without continued liaison with other providers, discussion of this stressor will be split off from either their substance abuse or primary psychiatric treatment. Coordinated treatment is necessary to manage drug abuse as we11as psychotic symptoms, and therapists in both substance abuse and primary psychiatric treatments need to agree about psychopharmacologic interventions and therapeutic strategy and goals. (3) Abstinence
Abstinence should be set as a goal rather than a requirement for admission to, or treatment in, the group, and creative ways to help achieve this goal need to be utilized. The use of peer pressure and peer approval for remaining drug-free, through announcing number of days “clean,” regular weekly discussions of “dirty urines,” and announcing achievement in vocational and educational areas that have resulted from abstinence are techniques that we have found successful. (4) Clear Expectations
There should be clear expectations that patients not use drugs on the premises or come to group “high.“All patients need to feel safe, and safety for the dually diag-
(5) Lapses
Although patients cannot attend group when intoxicated, they should be encouraged to return to group when sober and to discuss any lapses to drug abuse. Discussion of slips are useful as a way of facilitating development of coping skills and relapse prevention techniques. Reviewing “slips” in a nonjudgmental way allows patients to see for themselves where they made unwise decisions, rather than viewing themselves as weak and as failures. (6) Emphasis on Psychoeducation and Skill Building
An emphasis on psychoeducation and skill building is important. The averse effects of drugs of abuse and the medical interactions of these abused drugs with major psychiatric illnesses and with psychotropic medication should be explained clearly and repeated frequently. Patients can be encouraged to report their experiences in these areas, while the therapist makes a list for discussion based on the comments of patients. This serves two purposes. First, it allows patients to talk as “experts,” while therapists take notes on what they are saying, thus increasing the patient’s self-esteem. Second, it keeps patients involved as they listen to and relate to each others “stories.” Repeated discussion of the harmful effects of drug use, as experienced by members of the group, is essential to counter “euphoric recall” or the tendency of patients to remember only the positive aspects of drug abuse. Dually diagnosed patients can make good use of relapse prevention techniques (Marlatt & Gordon, 1985). They readily collaborate with therapists and peers in this cognitive and behavioral approach to treatment. Structured “pen and paper” exercises or the use of the blackboard to describe conditioned cues and to teach strategies to avoid high-risk situations or to control craving are excellent ways of getting patients to talk to each other (through the intermediary of the group leader or patient instructor) as well as to practice and rehearse these skills. Patients will often enjoy learning about early warning signs of relapse (such as overconfidence, beginning to socialize with drug-using friends, or feeling lonely, depressed, anxious, etc.). Initially they may take some pleasure in detecting these early warning signs in other patients, but ultimately they develop pride in their ability to recognize their own early warning signs. Role playing in the group and successful use of the skills learned in real life situations are a major source of pride and increased self-efficacy to group members.
Dual Diagnosis-Relapse
309
Prevention
(7) 12-Step Groups
Hall, R.C.W., Popkin, M.D., Devaul, R., &Stickney, S.K. (1977). The effect of unrecognized drug abuse on diagnosis and thera-
Finally, dually diagnosed patients need special encouragement to attend AA and NA groups. They often need to attend several different AA or NA groups before finally deciding on one in which they will be comfortable. Patients with psychotic and/or severe personality disorders have difficulty forming new relationships, and this should be acknowledged in their efforts to find comfortable self-help groups. Often the objectives of these groups conflict with the use of medications, and the need for medications in the treatment of their mental illness must be reinforced. In summary, in contrast to the frustrations so often experienced by clinicians and described in the literature on the treatment of dually diagnosed patients, utilizing the principles outlined in this report, treating the “dual diagnosis” patient can be a rewarding experience over the long term.
peutic outcome. American Journal of Drug and Alcohol Abuse, 4, 455-465. Hellerstein, D.J., & Meehan, B. (1987). Outpatient group therapy for schizophrenic substance abusers. American Journal of Psy-
chiatry, 144, 1337-1339. Kleber, H.K. (1988). Comments on problems in the treatment of the dual-diagnosed patient. Yale Psychiatric Quarterly, 10(2), 12-13. Kofoed, L., 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. Marlatt, G.A., &Gordon, J.R. (1985). Relapseprevention: Maintenancestrategies in addictive behavior change. New York: Guilford Press. Mueser, K.T., Yarnold, P.R., & Bellack, A.S. (1990). Prevalence of substance abuse in schizophrenia: Demographic and clinical characteristics. Schizophrenia Bulletin, 16(l), 31-56.
Negrete, J.C., Werner, P.K., Knapp, W.P., Douglas, D.E., &Smith, W.B. (1986). Cannabis affects the severity of schizophrenic symptoms: Results of a clinical survey. Psychological Medicine, 16,
515-520.
REFERENCES Barbee, J.G., Clark, P.D., Crapanzano, MS., Heir@ G.C., & Kehoe, C.E. (1989). Alcohol and substance abuse among schizophrenic patients presenting to an emergency psychiatric service. Journal of Nervous and Mental Disease, 117, 400-407. Drake, R.E., & Wallach, M.A. (1989). Substance abuse among the chronic mentally ill. Hospital and Community Psychiafry, 40, 1041-1045.
Richard, M.L., Liskow, B.L., & Perry, P.J. (1985). Recent psychostimulant use in hospitalized schizophrenics. Journalof Clinical
Psychiatry, 46, 79-83. Schnier, F.R., & Siris, S.G. (1988). A review of psychoactive substance use and abuse in schizophrenia:
Patterns
of drug choice.
Journal of Nervous and Mental Disease, 175, 641-652. Schwartz, S.R., & Goldfinger, S.M. (1981). The new chronic patient: Clinical characteristics of an emerging subgroup. Hospital and
Community Psychiatry, 32, 470-474. Siris, S.G. (1990). Pharmacological treatment of substance-abusing schizophrenic patients. Schizophrenia Bulletin, 16(l), 11 l-122.
9, pp.
305-309,
1992 Copyright
0
0740-5472/92 $5.00 + .OO 1992 Pergamon Press Ltd.
ARTICLE
Treatment of Dual Diagnosis Patients: A Relapse Prevention Group Approach RAJENDRA NIGAM, MD, RICHARD SCHOTTENFELD, MD, AND THOMAS R. KOSTEN, MD Substance
Abuse Treatment Unit, Department of Psychiatry, Yale University School of Medicine
Abstract - The authors describe the successful use of an adjunctive group psychotherapy for substance-abusing patients with major psychiatric disorders (bipolar, schizophrenia, schizoaffective, psychotic depression, and atypical psychosis). The group utilizes a psychoeducational approach that focuses on substance abuse causes and consequences, principles of recovery, and relapse prevention strategies. Eight patients with prolonged histories of abuse of cocaine, alcohol, marijuana, or other drugs were enrolled in this weekly group treatment at a community mental health center drug treatmentprogram, while continuing in treatment with their current case manager or primary therapist. Six of the eight patients achievedperiods of stable abstinence, documented by self-report, urine toxicology screens, continued group attendance, and improved social functioning. Case examples are utilized to illustrate the group process.
Keywords-Schizophrenia;
drug abuse; group therapy;
INTRODUCTION SUBSTANCE ABUSE OR DEPENDENCE is a problem for 20% to 50% of young, chronically mentally ill patients and leads to considerable excess disability (Drake & Wallach, 1989; Negrete, Werner, Knopp, Douglas, & Smith, 1986; Richard, Liskow, & Perry, 1985; Mueser, Yarnold, & Bellack, 1990; Barbee, Clark, Crapanzo, Heintz, & Kehoe, 1989). Patients with schizophrenia and other psychotic disorders are particularly likely to abuse stimulants, hallucinogens, marijuana, and alcohol (Mueser et al., 1990; Schnier, Siris, 1988). Compared to the non-substance-abusing psychotic patient, the psychotic substance abuser suffers more frequent and severe relapse, experiences higher rates of rehospitalization, and is considerably more difficult to engage in treatment (Drake & Wallach, 1989; Hall, Popkin, Devaul, & Stickney, 1977; Schwartz 8z Goldfinger, 1981). While substance abuse is often diagnosed in routine clinical practice, the failure to detect it contributes to
Supported by NIDA grants P50-DA04060, KOZ-DA0112 (TRK), 5T32-DA07238 and R18-DAO6190. Requests for reprints should be addressed to Thomas R. Kosten, MD,Substance Abuse Research Center, 27 Sylvan Avenue, New Haven, CT 06519.
psychoeducational;
dual diagnosis.
the worst outcome (Hall et al., 1977). Despite increased recognition of the importance of diagnosis and treatment of substance abuse in the severely mentally ill, there has been little discussion in the literature of successful treatment approaches for this population. Siris (1990) describes potential pharmacologic treatment approaches, all of which await systematic evaluation. Several investigators have pointed to the difficulty in integrating psychosocial approaches suitable to patients with schizophrenia (supportive, nurturing, nonconfrontational approaches designed to minimize anxiety and understand symptoms) with traditional drug abuse treatments (limit-setting, confrontational, and holding the abuser responsible for his or her behavior) (Kleber, 1988; Hellerstein & Meehan, 1986). There is also considerable controversy about whether dually diagnosed patients are best treated in psychiatric or substance abuse programs or whether conjoint treatment can be successful. Two groups of investigators have described outpatient group treatment approaches adapted for this population. Kofoed, Kania, Walsh, and Atkinson (1986) described an outpatient program for alcohol-abusing veterans with severe psychiatric disorders (schizophrenia, bipolar disorder, personality disorder, anxiety disorder, organic mental disorder). Of the 32 patients enrolled in their program,
306
R. Nigam et al.
14 also abused other drugs. The program included a weekly support group, routine prescription of disulfiram, monitoring of drug and alcohol use, and encouragement to attend Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings. Adjunctive individual or family therapy, day treatment, and relapse prevention or assertiveness training groups were available as adjunctive treatments. Drop-out rates from the program were quite high, with two-thirds dropping out within 2 months and 22% (7/32) remaining in treatment for one year or more. None of the drug-abusing patients remained in treatment more than 6 months. Hellerstein and Meehan (1987) utilized a weekly group format that focused on a psychoeducational approach, including engagement in the group, interpersonal skill development, and problem solving. Half of their initial 10 patients remained in treatment for one year (7 for 6 months), and there was a nonsignificant decrease in the average number of days hospitalized annually during the 3 years prior to entry into group treatment compared to the one year after entry (24.6 f 21.4 days/ year to 7.8 +_9.9 days/year). No data was presented describing changes in substance use following entry into the group. Because few descriptions of successful outpatient treatments for patients with severe coexisting psychiatric and substance use disorders are available, we are describing a successful group therapy approach in a community mental health center. The group psychotherapy focused on substance abuse recovery and was adjunctive to individual case management for these patients with major psychiatric disorders. Case examples are used to illustrate the treatment approach. METHOD Subjects
Since August 1989 we have conducted an outpatient dual diagnosis group with 3 male and 5 female patients whose ages ranged from 21 to 45 years (mean age = 3 1 years). They had individual case managers and received appropriate psychotropics, as described in the table. Procedure
The psychoeducational sessions were held once a week for one hour. The patients were encouraged to discuss their daily activities, including use of leisure time, and eventually to share their feelings. Group sessions also covered new or interesting social activities such as church fairs, games, dinners, and dances. Patients often made plans to participate together in these activities. Relapse and slips were handled in a nonjudgmental, supportive manner, and did not lead to automatic termination from the group. The patients were encouraged to discuss the details leading to these slips or
binges, such as when and where they occurred, what events lead to them, and whether they were alone or with others during the period of use. Thus the precipitants of relapse, including emotional upsets or feeling lonely, anxious, irritable, depressed, as well as slighted by others, and the situations leading to drug use were discussed in detail. Afterwards suggestions were made by the group on how to handle these situations in the future. Role playing by the patients was encouraged to allow acquisition of skills. Therapy was not limited only to the group sessions. The group therapists maintained an active liaison with other care providers, case managers, and vocational rehabilitation counselors. Formal social interactions between therapists and patients occurred on occasions when coffee and donuts were brought to the group. The patients discussed their absences and explained the reasons to the group. Unplanned absences were confronted by the group. Outcome
Outcome measures included patients’ attendance, retention in treatment, and abstinence. Drug abuse slips and binges were self-reported, and patients were monitored with weekly urine toxicologies. RESULTS Two patients (#4 & #5) dropped out of the program. They frequently abused marijuana and cocaine, and their urines were almost always positive. Two patients (#l and #2) attended more than 90% of all sessions and were invariably punctual. They achieved abstinence lasting 12 and 10 months, respectively, as verified by urine toxicologies. The other four patients attended approximately 80% of sessions, and all of their urines were negative for illicit drugs. Although all of her urines were negative for cocaine, patient #6 reported two relapses during 10 months of treatment. She continued to attend the group regularly in spite of these relapses. Case Histories
Case #I -Lapse to Drug Use. Patient #6 (ML) binged IV cocaine 9 months after entering the group. She reported this to the group at the next meeting and explained that one of her drug-abusing friends visited her and offered her cocaine. She told the group that she was feeling low on that day and was alone in her apartment without anything to do. She felt that she could not resist getting high, although she tried to resist at first. The group listened to her very carefully and sympathetically. They discussed and developed a relapse prevention strategy for this patient, as follows: 1. Don’t allow your drug using friends to visit you and say “no” boldly.
307
Dual Diagnosis-Relapse Prevention TABLE 1 Clinical Characteristics and Outcomes for Psychotic Substance Abusers Demographics
Psychiatric
Abused Drugs (maximum use) Cocaine
ID No. Sex Race Age 1 2 3 4
M F F F
W W W 6
30 27 21 34
Diagnosis
Meds
Bipolar Bipolar Psychosis NOS Schizo-Paranoid
LVprolixin LVtrilafon trilafon mellaril prolixin decanots LVprolixin activan LVprolixin restoril DMVChlorpromazine
5
M
W
27
6
F
W
27SA
7
M
B
37
Schizo
w
45
Depress psychotic
8
F
SA-manic
naltrexone
gmlwk 2.5 2.0 7
yr
ozlwk
Marijuana
yr jtslwk
yr
Other
16 NA 0 Heroin 7 Amphet
Months Positive Months Urines Abstain Rx 12 10 7
0 0 0
12 13 7
NA
6
? all
0
NA
6
few
0
10 4 3
30 ND 12
8 14 8
14 0 72
14
4
ND
20
7
19
<1
14
ND
14
2
9
1
4
54
13
49
13
Heroin
10
3.5
1.5
45
16
0
16
Heroin
6
0
0
0
10
10
2
0
Disconnect yourself completely from drug abusers. 3. Call one of the group therapists or any other member of the group when you are feeling low. When she encountered the same situation the following week, she was able to say “no” and control herself. In the next session she happily told the group that this strategy worked for her.
2.
Case #2-Problems
Alcohol
Outcomes
Patient #l missed two group sessions 6 months after entering the group. Upon return to the next sessions, the group asked about the reason for his absence. The patient reported that he had gone to the beach for the past 2 weeks. Members of the group confronted this behavior and scolded the patient for missing the group sessions. After these incidents, his unplanned absences stopped. With Attendance.
Case #3-Addition of New Members. The group developed intimacy and cohesiveness, but remained welcoming to new members. New members were treated empathetically and respectfully by the group. Although the group was interested in knowing the details about a new member, in order to understand him or her better, group members refrained from pressing with too many questions right away. Patient #8 joined the group 6 months after the group formed. She was depressed due to the recent deaths of her two teenaged children. She was quite guarded initially and stated that she disliked coming to the group. She felt the group was not the right place for her and did not want to continue. Following the encouragement of group members to stay within the group, she continued, and in the following sessions she began to talk more freely and discuss her
coke 2
10 6 ?l or5
feelings, including liking the group. Although she required inpatient hospitalization several weeks later due to severe depression, she continued to attend the group weekly while hospitalized. She has successfully maintained abstinence for 2 months since her hospital discharge. DISCUSSION While treatment approaches for the substance-abusing patient with a major psychiatric disorder are still evolving, it has been suggested that a unified team approach under one roof is superior to concurrent treatment in more than one setting. These cases suggest successful treatment, as measured by abstinence rates and decreased hospitalization, can be accomplished in a primary substance abuse treatment setting for the dually diagnosed with concurrent treatment by other providers. We believe that the following ingredients are needed for a successful group approach for the “dual diagnosis” patient. 1. Active therapists who start a small number of patients in the group (e.g., 3 or 4). 2. Good communication with any primary care providers who are not group co-therapists. 3. Abstinence should be a goal rather than a criterion for admission to or remaining in the group. 4. Clear rules regarding use of substances or drugs when patients attend group, including not attending if intoxicated. 5. An open discussion in the group of any lapses to drug abuse, 6. Emphasis on education and skill building.
308
7. Encouragement to use 1Zstep groups (i.e., AA, NA) beyond these psychotherapy groups.
R. Nigam et al.
nosed patient is particularly crucial, since they are often exploited by other drug users and dealers who are not psychiatrically impaired.
(1) Active Therapists
Since patients with chronic psychiatric disorders generally have poor social skills, it is important that therapists maintain an active stance, including making suggestions and actively containing the group process. Therapists need to model constructive confrontation for these patients so that the group process does not become chaotic and destructive. Since it is often difficult to engage these patients in group therapy, therapists must be willing to start with a small number (3-4 patients) and add to the core group, as these early patients are taught appropriate group behavior. Patient interactions will often be focused on the therapist at first, but ultimately patient-to-patient interactions can be fostered. (2) Good Communication
Good communication with primary therapists, case managers, and other care givers cannot be emphasized enough in an integrated approach. Successful treatment depends on patients revealing to their substance abuse group plans to stop their psychotropic medications, and on the group using its peer pressure to maintain medication compliance. Stopping antipsychotic medications is often a result of a major stressor related to a substance abuse lifestyle, and without continued liaison with other providers, discussion of this stressor will be split off from either their substance abuse or primary psychiatric treatment. Coordinated treatment is necessary to manage drug abuse as we11as psychotic symptoms, and therapists in both substance abuse and primary psychiatric treatments need to agree about psychopharmacologic interventions and therapeutic strategy and goals. (3) Abstinence
Abstinence should be set as a goal rather than a requirement for admission to, or treatment in, the group, and creative ways to help achieve this goal need to be utilized. The use of peer pressure and peer approval for remaining drug-free, through announcing number of days “clean,” regular weekly discussions of “dirty urines,” and announcing achievement in vocational and educational areas that have resulted from abstinence are techniques that we have found successful. (4) Clear Expectations
There should be clear expectations that patients not use drugs on the premises or come to group “high.“All patients need to feel safe, and safety for the dually diag-
(5) Lapses
Although patients cannot attend group when intoxicated, they should be encouraged to return to group when sober and to discuss any lapses to drug abuse. Discussion of slips are useful as a way of facilitating development of coping skills and relapse prevention techniques. Reviewing “slips” in a nonjudgmental way allows patients to see for themselves where they made unwise decisions, rather than viewing themselves as weak and as failures. (6) Emphasis on Psychoeducation and Skill Building
An emphasis on psychoeducation and skill building is important. The averse effects of drugs of abuse and the medical interactions of these abused drugs with major psychiatric illnesses and with psychotropic medication should be explained clearly and repeated frequently. Patients can be encouraged to report their experiences in these areas, while the therapist makes a list for discussion based on the comments of patients. This serves two purposes. First, it allows patients to talk as “experts,” while therapists take notes on what they are saying, thus increasing the patient’s self-esteem. Second, it keeps patients involved as they listen to and relate to each others “stories.” Repeated discussion of the harmful effects of drug use, as experienced by members of the group, is essential to counter “euphoric recall” or the tendency of patients to remember only the positive aspects of drug abuse. Dually diagnosed patients can make good use of relapse prevention techniques (Marlatt & Gordon, 1985). They readily collaborate with therapists and peers in this cognitive and behavioral approach to treatment. Structured “pen and paper” exercises or the use of the blackboard to describe conditioned cues and to teach strategies to avoid high-risk situations or to control craving are excellent ways of getting patients to talk to each other (through the intermediary of the group leader or patient instructor) as well as to practice and rehearse these skills. Patients will often enjoy learning about early warning signs of relapse (such as overconfidence, beginning to socialize with drug-using friends, or feeling lonely, depressed, anxious, etc.). Initially they may take some pleasure in detecting these early warning signs in other patients, but ultimately they develop pride in their ability to recognize their own early warning signs. Role playing in the group and successful use of the skills learned in real life situations are a major source of pride and increased self-efficacy to group members.
Dual Diagnosis-Relapse
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Prevention
(7) 12-Step Groups
Hall, R.C.W., Popkin, M.D., Devaul, R., &Stickney, S.K. (1977). The effect of unrecognized drug abuse on diagnosis and thera-
Finally, dually diagnosed patients need special encouragement to attend AA and NA groups. They often need to attend several different AA or NA groups before finally deciding on one in which they will be comfortable. Patients with psychotic and/or severe personality disorders have difficulty forming new relationships, and this should be acknowledged in their efforts to find comfortable self-help groups. Often the objectives of these groups conflict with the use of medications, and the need for medications in the treatment of their mental illness must be reinforced. In summary, in contrast to the frustrations so often experienced by clinicians and described in the literature on the treatment of dually diagnosed patients, utilizing the principles outlined in this report, treating the “dual diagnosis” patient can be a rewarding experience over the long term.
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