George A. Parks, Ph.D., Britt K. Anderson, Ph.D., G. Alan Marlatt, Ph.D.

Co-Occurring Disorders and the Practice of Psychology

Epidemiological research indicates psycho-active substance use is the most prevalent Axis I disorder. In addition, drug and alcohol problems are the most frequent comorbid condition associated with other mental disorders making accurate assessment and effective treatment of these psycho-logical problems more difficult. Axis I mental disorders and/or Axis II personality and developmental disorders co-occurring with psychoactive substance use disorders are referred to as “dual diagnosis,” “dual disorders,” Mentally Ill Chemical Abuser (MICA), etc.

While there is no agreed upon label for these problems, we prefer the term co-occurring disorders specifying the mental disorders and substances involved. Developing more effective treatment for co-occurring disorders is essential because of their increasing prevalence and their threat to the health and well-being of our clients.

Unfortunately, individuals suffering from co-occurring disorders generally encounter a treatment delivery system ill prepared to meet their needs (Marlatt and Roberts, 1998). High-thresholds for treatment entry in substance abuse programs may lead to denial of treatment altogether or treatment specific to alcohol and drug problems only. Conversely, clients presenting with co-occurring disorders may only be treated for mental disorders by psychotherapists who believe they cannot competently treat alcohol or drug problems. Even when co-occurring disorders are accurately assessed and diagnosed, they are often treated sequentially in the hope that the resolution of one will make treatment of the other easier.

When the disorders are treated concurrently, it is usually by different providers with the burden of case management left to the client. Worse yet, an individual may become the focus of competition among providers in a “dueling diagnostics” over client ownership and the “right” theoretical approach to the client’s problems. Criminalizing drug use creates yet another barrier to treatment for those who abuse or are dependent on illicit drugs. Fortunately, more integrated approaches to the treatment of co-occurring disorders are emerging. Psychologists have a vital role to play in the continuing development, evaluation, dissemination, and implementation of these more integrated therapeutic approaches.

“Developing more effective treatment for co-occurring disorders is essential because of their increasing prevalence and their threat to the health and well being of our clients.”
 
Miller and Brown (1997) argue persuasively that psychologists can and should acquire the training and supervised experience necessary to competently treat alcohol and drug problems. In discussing what psychologists have to offer in the treatment of co-occurring disorders, Miller and Brown suggest that (1) alcohol and drug problems follow the same principles of acquisition and change as other mental disorders, (2) substance use rarely occurs without related psychological problems, (3) empirically-supported approaches identified as most effective for treating alcohol and drug problems, such as cognitive-behavioral therapy (CBT), are practiced widely by psychologists, and (4) the clinical skills of psychologists include therapist qualities such as accurate empathy, which are associated with positive outcomes when treating substance use disorders.

To acquire the core knowledge necessary to treat co-occurring disorders, the American Psychological Association College of Professional Psychology offers a Certificate of Proficiency in the treatment of psychoactive substance use disorders. In addition, significant progress has been made in developing integrated psychosocial therapies for co-occurring disorders. Relapse Prevention and Harm Reduction are two such approaches.

Relapse Prevention and Harm Reduction

Cognitive-behavioral therapies (CBT), such as Relapse Prevention Therapy (RPT), have shown considerable promise as effective treatments for addictive behaviors (Irvin et al., 1999). More recently, Harm Reduction Therapy (HRT) has come forth as a humane and pragmatic alternative to traditional abstinence-based addiction treatment and to the moral model of substance abuse (i.e. “war on drugs”). Both RPT and HRT offer services to active users regardless of the ultimate goal of therapy (abstinence/ moderation) and recognize that therapeutic progress occurs in gradual increments or stages of change (Prochaska & DiClemente. 1992).

Relapse Prevention Therapy (RPT)

Relapse Prevention Therapy is a cognitive-behavioral self-management program created to help clients maintain gains achieved in addictive behaviors treatment. RPT consists of two interrelated components, (1) relapse prevention designed to help clients anticipate and avoid an initial slip or lapse, and (2) relapse management designed to reduce the intensity, duration, and harmful consequences of any slips that do occur. Following a lapse, relapse prevention therapists encourage clients to continue the journey of habit change by accepting that creating new behaviors involves both advances and setbacks.

Recently, RPT programs have been developed specifically for co-occurring disorders (Roberts et. al., 1999). Coping skills training forms the cornerstone of RPT, teaching clients strategies: (a) to understand relapse as a process, (b) to identify and cope effectively with high-risk situations, (c) to cope with urges and craving, (d) to implement damage control procedures during a lapse to minimize its negative consequences, (e) to stay engaged in treatment even after a relapse, and (t) to learn how to create a more balanced life-style. Recent treatment outcome research provides encouraging evidence for the effectiveness of RPT as a psychosocial treatment for alcohol and drug problems (Irvin et al., 1999).

Harm Reduction Therapy (HRT)

Harm Reduction Therapy (Marlatt, 1998; Marlatt & Roberts, 1998) refers to a treatment philosophy and set of interventions fostering a compassionate and pragmatic view towards individuals suffering from co-occurring disorders.

Rather than refer active alcohol and drug users with mental disorders to specialized treatment, harm reduction therapists meet these clients “where they are” in terms of readiness to change and attempt to reduce the harmful consequences of all of their interrelated problems. HRT focuses on improvement in the client’s overall psychosocial functioning and well being, as well as on the cessation, reduction, or moderation of drug and alcohol use.

From a harm reduction point of view, maladaptive behaviors can be placed on a continuum of harmful consequences. The goal of HRT is to move clients along this continuum in the direction of reduced risk and harm. Any step in the right direction is considered progress, with lapses and backsliding treated as a natural part of the change process. The strategies and procedures used in HRT reflect a public health orientation as well as an integrated approach to treatment.

The basic strategies of harm reduction are implemented by working clinically with individuals or groups, modifying the environment, and implementing changes in public policy. An important aspect of this approach is providing low-threshold access to services by not setting preconditions for treatment entry and by removing potential barriers to client participation.

Harm reduction therapists communicate an accepting attitude that reduces the stigma and shame associated with getting help for these problems. They provide a normalized and integrative approach to treatment that views the co-occurrence of substance use and other psychological problems as no different from any other behavioral health problem.

In HRT, treatment planning and goal setting are a collaborative process. The client communicates what is important for therapeutic focus; the therapist provides feedback, information, coping skills training, and support tailored to the changes the client seeks. The harm reduction therapist stays attuned to the client’s motivational state and skills deficits offering clients a strategic combination of motivational enhancement and skills training interventions (Baer et al., 1999). Additionally, HRT’s flexibility makes it well suited to serve individuals who are frustrating to work with clinically due to missed appointments, noncompliance with treatment, and vacillation in their commitment to change.

Harm reduction therapists first try to stabilize a client’s problem behaviors and prevent any further increase in harmful consequences. In this respect, the therapist’s role is to implement relapse prevention strategies to enhance the maintenance of change and to prevent the problem from getting worse. Once the most problematic behaviors have stabilized, the next goal of HRT is to help clients achieve a gradual reduction of the harmful consequences they are suffering, ranging from small decreases in risk and harm to the total cessation of some problematic behaviors.

Competence in delivering science-based addictive behavior treatment interventions is fundamental for therapists working within a HRT framework.  Cognitive-behavioral therapies (CBT) are particularly well suited to this approach, since they focus on using interventions based on the principles of learning, coping skills training, and a continuum model of behavior change (Jarvis et al., 1995).

Also essential to the harm reduction therapist are “client-centered” approaches such as Motivational Enhancement Therapy (MET) which focus on creating a viable therapeutic alliance, responding effectively to resistance to change, and supporting sustained motivation (Miller & Rollnick, 1991). HRT offers clients an integrated combination of motivational enhancement and skills training procedures delivered by an accepting therapist designed to sustain client motivation over time and to assist clients in learning how to achieve the changes they desire.

HRT interventions designed specifically for substance use include employing naltrexone to reduce alcohol craving, administering oral methadone to injection heroin users, or employing nicotine replacement procedures for smokers who want to cut down or quit. Regardless of the particular techniques used, HRT creates an inclusive and respectful therapeutic relationship.

Harm reduction therapists seek continual input from their clients. Unlike many treatment in the alcohol, substance abuse, and mental health fields, HRT does not establish treatment goals or administer interventions without collaboration and negotiation with the client.

In essence, Harm Reduction Therapy combines science with the art of healing encouraging psychologists to “get back to our basic commitment to treat all clients as real people rather than as labels and diagnoses, thereby, helping them to find their own answers, regardless of the particular problems causing their suffering” (Gordon, 1998, p. 76).*

References

Barr, J.S., Kiviahan, D.R., & Donovan, DM (1999). Integrating skills training and motivational therapies: Implications for the treatment of substance dependence. Journal of Substance Abuse Treatment, 17,1-2 15-23.

Gordon, J.R. (1998). Harm reduction therapy comes out of the closet. In G.A. Marlalt & JR. Gordon (Eds.), Treatment of Comorbid Addictive Behaviors: Harm Reduction as an Alternative to Abstinence. In Session. Psychotherapy in Practice, 4, 1, 1-8.

Irvin, J.E., Bowers, C.A., Dunn M.E., & Wang, M.C. (1999). Efficacy of relapse prevention: A metanalytic review. Journal of Consulting and Clinical Psychology, 67,563-570.

Jarvis, TJ., Tebbutt, J., & Mattick, R.P. (1995). Treatment approaches for alcohol and drug dependence: An introductory guide. West Sussex: John Wiley & Sons. Ltd.

Marlatt, GA. E.d.) (1998). Harm Reduction: Pragmatic strategies for managing high-risk behaviors. New York: Guildford Press.

Marlatt, G.A. & Gordon, J.R. (Eds.) (1985). Relapse Prevention: Maintenance strategies in the treatment of addictive behavior,. New York: Guilford Press.

Marlatt, GA. & Roberts, L.J. (1998). Introduction, In GA. Marlatt & J.R. Gordon (Eds.), Treatment of Comorbid Addictive Behaviors: Harm Reduction as an Alternative to Abstinence. In Session: Psychotherapy in Practice. 4,1, 1-8

Miller, W.R. & Brown. S.A. (1997). Why psychologists should treat alcohol and drug problems. American Psychologist, 52, 12, 1269-1279.

Miller, W.R. & Rollnick, S. (1991). Motivational interviewing: Preparing people to change addictive behaviors. New York: Guilford Press.

Protchaska, J.O. & DiClemente, C.C. (1992). In search of how people change: Applications of addictive behaviors. American Psychologist, 47, 1102-1114

Roberts, L.J., Shaner, A., & Eckman, T.A. (1999). Overcoming Addictions: Skills Training for People with Schizophrenia. New York: W.W. Norton & Co.

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