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The Drug and Alcohol Forum


by Wesley E. Sowers, MD
Clinical Coordinator, Center for Addiction Services
St. Francis Medical Center, Pittsburgh, PA


This paper describes a population of persons with severe mental illness which is comorbid with a significant substance use disorder. This population is frequently under served due to a lack of services designed to meet their needs. Addiction treatment services remain poorly integrated with mental health services in many service systems which results in gaps in the service continuum. Mental health treatment providers have traditionally been reluctant to provide service to persons who have been unable to establish an extended abstinence from psychoactive substances regardless of their psychiatric difficulties. Many of these persons are treated first in addiction treatment programs and addiction counselors often feel uncertain about how to meet the needs of this complex group of clients. Persons with comorbid substance use and psychiatric disorders often display a variety of disabling characteristics and behaviors which prevent them from easily engaging in community based treatment programs and developing motivation for change. This paper will examine some of the problems commonly encountered by addiction professionals when working with this population and will discuss various methods of facilitating stabilization and providing adequate attention to mental health issues while addressing substance use problems.

After completing this article, participants will:

  • Identify the percentage of persons with severe mental illness and substance abuse disorders
  • Identify common characteristics of patients with dual disorders
  • Recognize the barriers to successful intervention with dual disorders clients
  • Learn strategies for improving outcomes for clients with severe mental illness and substance abuse disorders

It has been estimated that between 50-75% of persons with severe mental illness in urban areas also suffer from the disorganizing and destabilizing effects of psychoactive substance use (Bauer, 1987; Raskin & Miller, 1993). Many of these people are young adults who have developed an illness in the era deinstitutionalization and have therefore have not spent significant periods of time in the state hospital system (Brown, Ridgely, Pepper, Levine & Ryglewicz, 1989; Kay, Kalathara & Meinzer, 1989). Often they have had difficulty succeeding in the community, unable to tolerate the intensely stressful circumstances with which they are frequently confronted. Many find themselves bouncing back and forth between prison, hospital, homeless shelters and the streets (Gelbert et al, 1988; Kay, Kalathara & Meinzer, 1989).

Psychotic illnesses and severe mood disorders co-existing with substance use often present a complicated picture and it may be difficult to separate the effects of one from the other. All are chronic relapsing illnesses which tend to act synergistically (Dixon, Haas, Weiden, Sweeney & Frances, 1990; Minkoff, 1989). In some cases, an initial psychiatric disorder with psychotic manifestations (such as schizophrenia or bipolar disorder) may, for a variety of reasons, create a predisposition and vulnerability to substance use (Caton, Gralnick, Bender & Simon, 1989; Turner & Tsuang, 1990). Likewise, severe mood disturbances often lead to significant involvement with substance use. In other cases, heavy substance use precipitates psychotic symptoms or mood syndromes which do not readily resolve even in the absence of continued use. Often, however, it is unclear whether one of these illnesses is primary, and the distinction may be of little significance in treating these dual disorders (Lehman, Myers & Corty, 1989).

In combination, these conditions may create (and maintain) a variety of disabilities. Learning and other cognitive skills may be impaired by chronic thought disorders or poor attention span. Interpersonal interaction and social skills are often adversely affected by neediness, demands for immediate gratification of desires, and reduced understanding and concern about the needs and feelings of others. Coping mechanisms and problem solving skills are thrown into disarray frequently by poor modulation of affect, intrusive and disorganizing hallucinations, delusional thoughts, hopelessness or poor concentration (Caton, Gralnick, Bender & Simon, 1989; Kay, Kalathara & Meinzer, 1989). These deficits make it more difficult for people to function adequately (and independently) in a social milieu in which they need to make decisions based on sound judgements. Poor choices are often made in the face of uncontrolled impulses and unmanageable stress, compounding pre-existing problems. Consequently, these clients experience themselves as failures as they measure themselves against "healthy" members of the community. They are frequently subjected to social stigmatization which reinforces low self esteem and denial of illness and disability. They often react angrily to this devaluation (or on the other extreme - infantilization) and this, along with other interpersonal deficits, leads to the erosion and eventual destruction of support systems. Ambivalence toward their dependence leads to antagonistic relationships to authority figures and rebellious behavior which often further separates them from those who may offer help. Powerlessness and hopelessness become ingrained and many of these people end up feeling alienated, lonely, frightened, bored, and desperate as a vicious cycle perpetuates itself (Carey, 1989; Turner & Tsuang, 1990).

Persons suffering from these comorbid disorders often find that even when they are willing or able to seek treatment for their difficulties, there are few options available to them. Despite recent trends in mental health delivery systems to develop capabilities to adequately address substance use problems as part of integrated programming for persons with dual disorders, many programs remain reluctant to address the needs of these clients, particularly if they have not established extended periods of abstinence (Ries, 1993). Even those programs which have attempted to develop programming to address their needs, may have limited understanding of the addiction process and its treatment. As a result, persons who are severely impaired may not be adequately served by mental health systems. These clients are often referred to the addiction treatment system with the expectation that addiction treatment will allow them to establish some degree of abstinence.

Not unlike the mental health systems mentioned above, addiction treatment programs which are willing to work with these clients are often not well prepared to do so and available programming may be of limited value in addressing the needs of persons with dual disorders. Traditional addiction treatment paradigms are often too stressful to engage these clients and clinicians are frequently at a loss to understand how to alter these methods to better suit the special problems they present with (Inderlin & Belisle, 1991). An understanding of mental illnesses and their interactions with the addiction process is essential to the development of effective therapy for these individuals and most addiction treatment professionals are not adequately trained in this regard. What are the basic issues that must be addressed by addiction treatment programs who work with these individuals in the absence of more appropriate integrated programming?

Perhaps the most important characteristic of programs and professionals that would provide services to this population is flexibility. Traditional approaches to treatment must sometimes be discarded in order to engage individuals who may have limited ability to tolerate the stress generated by these approaches. Clinicians must be capable of adapting and repackaging interventions in a manner that can be incorporated by clients who display disabling psychiatric symptoms. It must be recognized that these conditions will often make the establishment of abstinence a more protracted process, and that rejection in the face of continued use will only make future attempts to engage these individuals in a recovery process more difficult. The goal of total abstinence for such clients is unrealistic, particularly early in their treatment, as several authors have recognized (Caton, Gralnick, Bender & Simon, 1989; Minkoff, 1989; White & White, 1989). Occasional and even persistent relapses must be tolerated, providing clients an opportunity to work on reducing their frequency over time. Although working toward abstinence is important, the main goal of treatment shall be to do whatever it takes to help their quality of life.

If this hurdle can be surmounted, much can potentially be accomplished. Clinicians will need to become familiar with some of the special characteristics of this population. Denial may be particularly tenacious in persons with dual disorders. Harsh confrontation may drive these clients away from treatment rather than move them toward recognition of their problems. Social isolation is often a result of poor social skills and management of affect and impulses. These individuals are frequently very sensitive to perceived criticisms. Special efforts may be needed to establish a relationship and engagement in the treatment process (Kofoed & Keys; 1988). Drugs are often seen as the only effective way to modulate unpleasant emotional states or hallucinatory experiences (Turner & Tsuang, 1990). External factors will often be seen as the cause for negative consequences which are in reality related to substance use. Insight into need for treatment is often transient or obliterated by impulses to escape the dysphoric feelings associated with this recognition and its implications. The resulting denial allows them to unrealistically invest in the proposition that they will be able to maintain their health and abstinence independently (Dixon, Haas, Weiden, Sweeney & Frances, 1990).

There has been much recent attention to the engagement process and stages of change (DiClemente & Hughes, 1990; Kofoed & Keys, 1988). The importance of meeting these clients where they happen to be cannot be over stated. The likelihood of involving persons with dual disorders in a change process will be slight if the conditions for participation in formal treatment are overly rigid and prohibitively demanding. Addiction providers may lament that flexible standards are destructive to a treatment milieu which is based on consistency. This legitimate concern points to the need to develop specialized programming for unique populations where the milieu is a significant element of the treatment plan (Bartels & Thomas, 1991; McLaughlin & Pepper, 1991). As with other addiction services, the development of a full continuum of services will enable the provider to meet the needs of persons regardless of the stage of the their illness. Unfortunately, specialized services for clients with dual disorders at all levels of care are currently unavailable in most systems (Lehman, Myers, Dixon & Johnson, 1994; Lehman, Myers, Johnson & Dixon, 1995; Ries, 1993).

Persons with dual disorders often require a full array of services such as supported housing, case management, and vocational rehabilitation (Bartels & Thomas, 1991; McGlynn, et al., 1993; Quinlivan, et al., 1995). These services are often beyond the scope of what addiction treatment centers are capable of providing. Recent experience indicates that integrated approaches to the treatment of dual disorders are most effective but when such programs are not available, parallel treatment of the co-existing disorders may be adequate (Inderlin & Belisle, 1991; Minkoff, 1989; Ries, 1993). Parallel treatment has the best chance or success when it is well coordinated and consistently administered. While many mental health systems may not be comfortable to act as the sole provider of services for this population, they will frequently be willing be collaborate with the addiction treatment provider to develop more comprehensive services. This type of close collaboration and coordination will markedly improve the chances for success when working with persons with dual disorders (Lehman, Myers, Dixon & Johnson, 1994; Ries, Mullen & Cox, 1994).

Treatment planning for persons with dual disorders will have several unique considerations regardless of the stage of illness and the level of care. Some of these unique elements will be briefly discussed.


Information must be provided to clients on a variety of topics related to mental illness and substance use. While psychoeducation is a central modality in many dual diagnoses rehabilitation programs (Brown, Ridgely, Pepper, Levine & Ryglewicz, 1989; Carey, 1989; Kofoed & Keys, 1988), the learning objectives and the exact content to be communicated are frequently vague or poorly defined. There has been some suggestion that individuals with cognitive deficits due to disordered thinking are unable to benefit from structured learning situations. Despite these doubts, experience suggests that by using a participatory style in group sessions, short term retention of information can be good.

A curriculum consisting of a variety of topics should be employed with clear objectives and content for each session. Topics should include information regarding psychiatric symptoms, psychiatric illnesses, addictive substances, interactions of substance use and mental illness, medications, relapse prevention, problem solving and HIV education (see Table 1 below).

Manuals may be prepared which will provide instructors with an outline for organizing discussions of these topics and a series of questions might be developed to evaluate client's retention of covered issues (Ryglewicz, 1991). Teaching technique must remain somewhat flexible, allowing the instructor to develop a style that he or she finds comfortable. The manual will only provide some standardization to the content of each of these topics. Each group consists of 10-12 participants and each session lasts 45-60 minutes.

Clients should receive individual counseling and reinforcement of concepts introduced in the group sessions. The objective of this aspect of treatment program is to begin to destigmatize and demystify these illnesses and to begin the process of breaking down denial. As this objective is met, problem solving and decision making will be enhanced, insight will improve, and clients' ability to remain in treatment and function more independently will increase.


The use of medication as a significant part of the treatment plan may be an element that is foreign to the addiction professional. Medication has often been seen as antithetical to a ‘pure’ recovery process by the addiction treatment community as well as the recovery community. It must be recognized, however, that while medication is not an answer to the dysphoria and discomfort that is often associated with early abstinence, it may be an essential facilitator of recovery for persons that experience severe psychiatric symptoms which are not substance or abstinence induced. Psychiatric illness may be disabling to persons attempting recovery and is often a significant cause for relapse. If not adequately addressed with medication, a significant roadblock to early recovery will be in place (Kosten & Kleber, 1988).

When medication is needed, or when there is reason to believe that it may be needed, the active involvement of a qualified psychiatrist will be a valuable asset. Programs which do not employ the services of a psychiatrist on a regular basis would do well to consider doing so. While the management of medications by a psychiatrist from another agency or practice may provide some support, the special circumstances of persons with dual disorders are best addressed by a psychiatrist who is part of the treatment team and who is knowledgeable about addictive illnesses.

Dually diagnosed clients may bring certain erroneous impressions regarding medication to the treatment process. Both the prescribing physician and therapeutic staff will need to be aware of their client’s perception of the medication that may be prescribed for them. There are two major perspectives that individuals may present with. The first, and perhaps the most common is a medication seeking attitude. This is most common among clients who are ambivalent about change. These persons may view medications as they view drugs, expecting a fast and easy solution to dysphoric states. They can be easily discouraged when medication use does not meet these expectations. This group may rely on medication as an external solution to their addiction and may mistakenly believe that treatment will allow them to avoid making a strenuous effort to achieve recovery. In some cases, these clients may see medication as a means to continue their drug use without unhappy side effects. It is not uncommon to observe an enhanced placebo effect. Antidepressants which normally require several weeks to produce a full clinical response may elicit and immediate response in persons who have mistaken ideas about their powers.

The second perspective that clients may bring to pharmacologic interventions is a medication rejecting attitude. This may result from significant denial of mental health difficulties. These individuals may find an identity as a problem substance user more acceptable than being labeled as mentally ill. Others may see medications as a "cop out" after having adopted a stoic, take control attitude as they begin their recovery. There may be an element of self punishment in the rejection of medication, and a belief that suffering is a necessary part of recovery. These individuals may formulate the use of medication as another failure in a long string of failures. This perspective may be promulgated by the recovery community in some cases. Whether one of these two belief sets is present, or some other variation, it will be important to understand each clients expectations and beliefs about medication use and address any misunderstandings that may be present. Successful treatment with psychoactive agents will limited without this effort (Gastfriend, 1993).

For many clients, recognition of the need for the indefinite use of psychoactive medication is a key to continued stability. The troublesome side effects associated with many of the commonly used medications, frequently lead to reduced adherence to recommended medication regimens or to the use of street drugs as a means of diminishing their impact. Fortunately, many of the newer psychiatric medications

are more benign than those of the past, and side effects are usually tolerable. Despite this, frequently clients feel their concerns about medications and their side effects are not heard. They may feel that they have little control over, or even input in, the determination of what medications they use and how much. This is particularly disturbing when medication use results in significant discomfort.

With these concerns in mind, emphasis should be placed on educating clients about the medications they consume as well as medications their peers consume. This education can take place individually and in group formats. Information about side effects, adverse reactions, medication/drug interactions, is provided and tailored to the individual need and comprehension level of each client. Their knowledge is reinforced over the course of their treatment (Ryglewicz, 1991).

Clients are also encouraged to assume an active role in the management of their medication. Their unique familiarity with their own body's response to medication is supported and their contribution to establishing a rational treatment plan is respected and clearly considered. Clients are encouraged to remember and record their medication history to provide a basis upon which they can make sound decisions and provide useful information to future providers. As their experience as an active participant in decisions regarding medication grows, their ability to avoid irrational decisions and to respond to provider advice increases.

In addition to medication used to address psychiatric symptoms, medication may be employed to aid detoxification and reduce craving. Recent reports have indicated that Naltrexone may be a useful adjunct to treatment in for dually diagnosed individuals who are alcohol dependent. Education regarding the limited usefulness of many of these aids is stressed, however, and clients are encouraged to recognize that behavioral changes remain the most effective way, and often the only way, to maintain abstinence.

Social Rehabilitation

Strategies to improve social functioning help overcome the isolation and loneliness that lead to boredom, despair and frequently substance use. Clients can be assisted in developing increased awareness of their own emotional life and how they are experienced by others. Improving social skills and interaction in cooperative projects helps to increase tolerance and trust, thereby facilitating the formation of fulfilling relationships and support systems. Exposure to interesting and enjoyable activities in a social setting allows clients to develop alternatives to substance use as their only means of pleasure (Nikkel, 1994).

A variety of interventions have been designed to achieve these objectives. Expressive - supportive psychotherapy groups are relatively unstructured and have an open agenda. Leaders usually play an active and directive role. They are generally led by a member of the treatment team and provide opportunities for ventilation, affiliation, identification, feedback, as well as many of the other therapeutic qualities identified by Yalom (1985).

Another important sphere of attention is family relations. Many clients come from dysfunctional and broken families which have little or no involvement with them at present. Family relations and associations continue to have a powerful impact on their behavior, however, many having experienced some form of abuse during some period of their development. Groups focusing on family issues may provide a forum for examining these issues and identifying with others who may have had similar experiences. A format using video excerpts from popular television programs and discussion may be successful in developing interest and participation. For clients who continue to have family members involved in their lives, multi-family groups or individual family meetings can be helpful. These sessions can follow a psychoeducational format, but they may also become a forum for family members to express concerns or fears and widen their own support systems (Ryglewicz, 1991).

Recreational and vocational activities are an essential element of successful social rehabilitation for these clients. Cooperative or team activities are particularly emphasized, providing opportunities for interaction and developing recognition of common interests. Creative arts, vocational training, and work experiences are among the activities that can be made available through the addiction treatment center.

Self Esteem Building

Providing opportunities for clients to take an active role in decisions affecting their lives and those of their peers and developing a recognition that they have unique qualifications to support each other's recovery enhances self-esteem and independence. Participants will be able to experience success within the context of their disabilities by working cooperatively to solve problems and to maintain health. Such experiences help overcome feelings of hopelessness, worthlessness, and despair and allow clients to re-evaluate some of the negative responses to mental health care providers that dependence fosters.

Traditional self help groups should be encouraged. Many clients may have had difficulty relating to these groups in the community, particularly when they feel intimidated or unable to relate well with persons who have not experienced the disabling effects of a significant mental illness. Helping clients to find the right groups for supportive affiliation will be an important function of the treatment program. A variety of other group activities may be developed to help support autonomy and self-esteem. Individual supportive therapy will also be valuable in enhancing progress toward a healthier self-concept (Kaufman, 1989).

These four areas of intervention are seen as preliminary or preparatory treatment in the overall process of recovery. For many individuals, who have had great difficulty functioning in a community setting for extended periods, exposure to intensive treatment in an inpatient setting may be their best chance to reverse this pattern and integrate into community living and treatment. For others, integrated outpatient programming will be sufficient to address ongoing needs and to guide them toward and extended period of abstinence. In most cases where active use remains a reality, more structured and intensive treatments will be required. Ideally, treatment philosophy should be consistent between inpatient and community providers and coordination and careful transition are key ingredients to maintaining stability during this process. Introduction to and active participation of community providers in treatment during any inpatient or residential treatment is one way to facilitate a successful discharge.


An approach to the treatment of persons with dual disorders who present for treatment in addiction oriented service system has been described. These clients have often had difficulty finding appropriate services due to a scarcity of programs which contain expertise in both mental health and addiction treatment. Overly rigid adherence to traditional treatment paradigms has lead to difficulties engaging persons affected by these dual disorders. Their tolerance for confrontation is low and they often have fewer internal controls to avoid making impulsive, maladaptive decisions. These problems can be addressed if clients can be persuaded to remain in treatment in a nonthreatening, nonjudgmental atmosphere. Addiction professionals will need to broaden their understanding of psychiatric disorders and their interaction with substance use disorders. Incorporation of treatment elements which enhance self esteem, improve social functioning, educate on mental health issues, and facilitate successful use of prescribed psychotropic medication into established treatment concepts will help guide these individuals toward abstinence, an improved quality of life, and eventual recovery.


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(Record Answers for SOWERS Test on Answer Sheet)

  1. At percentage of persons with severe mental illness also suffer from a substance use disorder?
  2. a. 10 - 20%
    b. 25 - 40%
    c. 40 - 60%
    d. 50 - 75%

  3. Which of the following disabilities is not commonly seen in persons with dual disorders?
  4. a. Poor social skills
    b. Poor motor coordination
    c. Disrupted cognition
    d. Problem solving deficits

  5. Which of the following is not a common characteristic of persons with dual disorders ?
  6. a. Tolerant
    b. Low self esteem
    c. Interpersonal difficulties
    d. Antagonism toward authority figures

  7. What is the most important characteristic of treatment programs providing care to persons with dual disorders?
  8. a. Knowledge of mental health issues
    b. Knowledge of addiction issues
    c. Flexible approach to treatment
    d. Strong and established treatment philosophy

  9. What aspect of treatment planning for persons with dual disorders may be most unusual for professionals working in addictions programs?

a. Educational programming
b. Family treatment
c. Social rehabilitation
d. Medication management