In the past, traditional treatment methods for drug addiction and alcoholism have been characteristically intense and confrontational. They are designed to break down a client’s denial, defenses, and/or resistance to his or her addictive disorders, as they are perceived by the provider.

Admissions criteria to substance abuse treatment programs usually require abstinence from all illicit substances. Potential clients are expected to have some awareness of the problems caused by substance abuse and be motivated to receive treatment.

In contrast, traditional treatment methods for mental illness have been supportive, benign and non-threatening. They are designed to maintain the client's already-fragile defenses.

Clients entering the mental health system are generally not seeking treatment for their substance abuse problems. Frequently clients within the mental health system who actively abuse drugs and alcohol are not formally identified. If they are, they do not admit to such substance use.

As some attention began to focus on clients with both substance abuse problems and mental illnesses, it quickly became apparent that new methods and interventions were necessary.

Working with dual disorder clients who deny substance abuse, who are unmotivated for substance abuse treatment, and who are unable to tolerate intense confrontation, required a new model, a non-confrontational approach to the engagement and treatment of this special population.

I first developed such a treatment model in 1984, with the goal of providing nonjudgmental acceptance of all symptoms and experiences related to both mental illness and substance disorders.

A brief history

Such treatment interventions and integrated programs -- which truly adapted to the needs of severely mentally ill chemical abusers -- had their genesis in 1984 at a New York state outpatient psychiatric facility.

In 1985, these integrated treatment programs were implemented across multiple program sites. Concurrently, treatment and program elements were taught through training seminars in New York as well as nationally. In September 1986, the New York State Commission on Quality of Care (CQC) released the findings of 18 months of research.

In their report, they described the detachment and downward spiral of dually diagnosed consumers, who were bounced among different systems with "no definitive locus of responsibility."

As a result, New York’s governor designated the state Office of Mental Health as the lead agency responsible for coordinating collective efforts for this population. The commission visited the dual diagnosis programs developed in 1984, and declared the treatment interventions, the training, and integrated programs to be positive solutions to the dilemma.

When a 1987 Time magazine investigation of these programs revealed that at least 50 percent of the 1.5 million to 2 million Americans with severe mental illness abuse illicit drugs or alcohol -- as compared to 15 percent of the general population -- the "doubly troubled" were brought to the attention of the general public.

A gubernatorial task force declared its vision for statewide program development and a training site for program and staff development in the treatment of mentally ill chemical abusers was created to attain that vision.

Short-term and on-going training and program development was provided to hundreds of New York’s treatment providers at both state and local mental health and substance abuse agencies. Consumer-led and family-support programs were also developed.

The state produced a training video that demonstrated the integrated treatment model, however, the training site closed in 1990 due to budgetary considerations. Programs and groups that grew out of this model continue to be an important nucleus of current services in New York and nationally.

These treatment interventions evolved in adaptation to the needs of the dual diagnosis clients. Methods and philosophies clearly differed from traditional substance abuse treatment.

Consumers who were actively abusing substances, physically addicted, unstable, and unmotivated, were engaged through a "non-confrontational" approach to denial and resistance, and acceptance of all symptoms. Consumers participated in treatment groups without pressure to self-disclose, and explored topics from their own perspectives.

Subsequent providers either learned from this model, or came upon similar processes through their own experimentation.

How it works

The phase-by-phase interventions from "denial" to "abstinence" begin by assessing the client's readiness to engage in treatment. Readiness levels are accepted as starting points for treatment, rather than points of confrontation or criteria for elimination.

Mental health and substance abuse programs who integrate these programs, implement screening forms to identify clients who have dual disorders.

Identified clients are followed up for engagement and assessment of readiness. Clients are encouraged to participate in dual diagnosis treatment even if they do not accept or agree to the presence of a substance disorder.

Clients may participate on the basis of their interest in learning more about mental health and substance disorders, or with the belief that they may be able to lend support to others who are seeking help, among other reasons. The process then proceeds from identification to the engagement phase.

The objective in the engagement phase is to develop comfortable and trusting relationships and, if possible, to expose the client to information about the etiology and processes of these illnesses in an empathic and educational manner.

The client is given the opportunity to critique the information presented, rather than being told about any particular fact.

Interaction effects between symptoms of mental illness and substance disorders are also included in this exploration. Clients at this phase are not required to disclose personal experiences or to admit they use or abuse substances until they are comfortable doing so.

The inclusion of educational materials and discussion topics allows for discussion of the issues and impersonal participation. Clients are encouraged to move along a continuum from “exploration” to “acknowledgment” of their symptoms.

This includes:

* attaining a level of trust necessary to discuss their own use of substances and/or symptoms of mental illness;

* the exploration and subsequent discovery of any problems or interaction affects that result from substance use and mental health symptoms;

* considerations and motivation for addressing these problems;

* active engagement in a process of treatment that seeks to eliminate symptoms;

* attainment of partial or full remission;

* and participation in an individualized maintenance regime for relapse prevention.

These programs are implemented as components of existing mental health, and substance abuse programs, and thereby provide integrated treatment.

Materials developed for the implementation of this treatment process include screening instruments, with separate instruments used for detecting substance abuse among persons who are known to have a mental illness, and detecting mental illness among those persons who are known to have substance abuse/dependence.

The pre-group interview provides engagement strategies and a scale to indicate the client's level of readiness or motivation to participate in treatment. The comprehensive assessment reviews past and present mental illness, substance abuse, and interaction effects.

Forms for progress reviews and updates include criteria necessary to measure change throughout the phases of movement toward readiness for treatment, active treatment, and relapse prevention.

Forms for data collection include programmatic information regarding statistics, client participation, and outcome.

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For rest of article, see source document
http://www.treatment.org/Topics/pdf/SciaccaRemovingBarriers.pdf

From the Dual Diagnosis Website
http://users.erols.com/ksciacca/

Article reprinted with kind permission of the author.