The treatment settings for long-term treatment, rehabilitation, and recovery from dual disorders include outpatient, day treatment, and residential settings. Ideally, treatment intensity is dictated by disorder severity and motivation for treatment, as well as by personal and local treatment resources. In more severe conditions, ongoing dual disorder case management is essential. The management of long-term severe conditions is described in more detail in the chapter on psychotic disorders (Chapter 8).
With regard to the initiation and maintenance of sobriety in patients with dual disorders, another way of looking at acute, subacute, and long-term phases involves a four-step approach that leads to abstinence. This approach is particularly important for patients with severe psychiatric problems and an AOD use disorder (Minkoff and Drake, 1991; Ries, 1993a).
Individual case management. Individual case management provides an initial introduction to treatment goals and concepts and may provide assistance with regard to crises, housing, and entitlements. An individual treatment plan is developed.
Persuasion groups.Patients who display strong denial about their AOD use disorder and lack motivation can attend persuasion groups, which provide basic AOD education and treatment engagement. Premature, potent, and direct confrontation and an insistence on abstinence should be avoided since these approaches may prompt more fragile patients to leave treatment.
Active treatment groups. Active treatment groups consist of patients who have accepted the goal of abstinence and are relatively mentally stable. These groups use supervised peer confrontation and a psychoeducational-behavioral approach to AOD abuse.
Abstinence support groups. Finally, abstinence support groups consist of patients who are essentially committed to abstinence and are relatively stable mentally, who require ongoing education and support for sobriety and the development of relapse prevention skills.
Psychiatric and AOD abuse treatment issues are woven into the groups in such a way that concrete issues (such as medication compliance) are addressed in persuasion groups, while abstract concepts (such as self-image) are addressed in active treatment or abstinence support groups. Some patients — such as severely psychotic patients — may not be able to advance beyond persuasion groups or active treatment groups.
General Assessment Issues
Each of the following chapters will address assessment and evaluation issues relative to specific psychiatric disorders. Specific assessment tools may be recommended for certain interventions and certain settings. Irrespective of the treatment or intervention setting, and notwithstanding the crisis that may have initiated the treatment contact, all treatment contacts with patients who may have dual disorders should include a basic screening for psychiatric and AOD use disorders. These issues are addressed in detail in the chapters on mood, personality, and psychotic disorders. With respect to both psychiatric and AOD use disorders, the assessment process should be sensitive to biological, psychological, and social issues.
Full assessments of patients with dual disorders should be performed by clinicians who have certified training in the areas that they assess. However, clinicians who are not certified can learn to perform screening tests. Assessments of patients who may have dual disorders should include at least a brief mental status exam to assess for the presence and severity of psychiatric problems, as well as a screening for AOD use disorders.
The “ABC” model described on the previous page is a simple screening technique for the presence of psychiatric disorders. The CAGE questionnaire and the CAGE questionnaire modified for other drugs (CAGEAID) are rapid and accurate screening tools for AOD use disorders (Exhibit 3-2). The substances used most often by patients with dual disorders are the same as those used by society in general: alcohol, marijuana, cocaine, and more rarely, opioids. It is recommended that all front-line AOD and mental health staff receive detailed training in the use of a mental status exam and AOD screening tests.
From the Treatment Improvement Protocol (TIP) Series, Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse. U.S. Dept. of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, 1995-1996.
Ries, R. (2007). Mental Health And Addiction Treatment Theories and Approaches. Psych Central. Retrieved on June 20, 2013, from http://psychcentral.com/lib/2007/mental-health-and-addiction-treatment-theories-and-approaches/
Last reviewed: By John M. Grohol, Psy.D. on 30 Jan 2013
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