Long-Term Treatment Goals

Treatment goals should include consolidating the AOD-free lifestyle, establishing psychiatric stability, achieving social independence and stability, and enhancing vocational choices and goals. Long-term treatment can be viewed as a maintenance period — a time for personal growth and development and consolidation of long-term, satisfying patterns of social adaptation.

Addiction Treatment

The long-term management of addiction includes participation in 12-step programs and other support groups, individual and group counseling, and in some cases, continued participation in a treatment program. The severity of a patient’s illness should be matched with the appropriate treatment intensity and level of care.

Patients with dual disorders who experience low levels of psychiatric impairment require a level of care that can be provided in traditional low-structure abstinence-oriented addiction treatment programs. Dual disorder patients who experience severe psychiatric symptoms or cognitive impairment require a more intense level of care such as that provided by a highly structured dual disorders treatment program. Matching patients to the appropriate treatment and level of care can help achieve desired outcomes.

Psychiatric Treatment

The majority of patients receiving treatment for combined mood disorders and addiction improve in response to treatment. When they don’t improve, there should be a reevaluation of the treatment plan. For example, a patient receiving antidepressant medication who is abstinent from AODs but anhedonic (unable to feel pleasure or happiness) requires a careful evaluation and assessment to identify resistant psychiatric conditions that require treatment. In this example, based on assessment, an additional treatment service such as psychotherapy may be added. Indeed, psychotherapy has been shown to improve the efficacy of addiction treatment and of psychiatric treatment that involves antidepressant medication.

When patients do not improve as expected, it is not necessarily because of treatment failure or patient noncompliance. Patients may be compliant and plans may be adequate, but disease processes remain resistant. Persistent attention to the addictive process and its complications as well as meticulous attention to psychiatric therapy usually leads to improvement. However, patients with severe and persistent AOD and mood disorders should not be seen as resistant, manipulative, or unmotivated but as extremely ill and requiring intensive treatment.

Long-Term Treatment Needs

Patients who have experienced sexual, physical, or psychological abuse may have problems that surface during acute treatment or that are identified during long-term treatment evaluations. Treatment needs resulting from these types of abuse should be addressed in the long-term treatment plan.

The resolution of problems related to sexual, physical, and psychological abuse usually requires specialized, long-term treatment. However, these problems should be addressed whenever they surface in any phase of treatment for AOD and mood disorders.

For example, addressing these problems during early recovery should be viewed from the perspective of anxiety reduction and consolidation of abstinence. At that phase of recovery, the treatment goal is to have patients contain or express their potent and surfacing feelings without using alcohol and other drugs. Later in recovery, these problems can be dealt with in terms of long-term stabilization and psychological resolution.

Continuing addiction counseling and participation in group support activities are useful to help consolidate abstinence. These recovery maintenance activities include participation in social clubs, 12-step programs, religious organizations, and other cultural institutions. Community-based activities can provide long-term stability to these patients.

At this stage of treatment, special treatment needs can be identified through targeted testing in such areas as neurologic, cognitive, and personality disorders. Special treatment needs should be specifically addressed by the appropriate treatment strategy. STD and HIV risk reduction, evaluated throughout the progression of illness, should now address the importance of long-term stable changes in behavior.

Family Issues

Family members should be evaluated for AOD problems in acute and subacute stages when the family members begin to become involved in the patient’s treatment. There is usually adequate time to deal with family issues in the subacute phase, when personnel and family members become acquainted. Family members include household members as well as members of the patient’s support system.

The family often needs and should receive treatment. After careful evaluation of family dynamics, the presence of addictive disorders or codependent behavior in the family should be evaluated. The presence of AOD and mood disorders in the patient is the best predictor of AOD and mood disorders in the family. A family history of one disease increases the risk for the other; a family history of both disorders multiplies the risk factor.

Family therapy can be provided on site. Individual family members should be referred for the treatment of specific problems when required. It is often necessary to help families “mop up the rage” that has accumulated. It is important to determine when to deal with the family as a group to resolve conflicts and when members need to work with a therapist alone to develop independence from dysfunctional reliance. Participation in Al-Anon and related self-help groups for family members should be encouraged and incorporated in the treatment schedule for family members.

Eating Disorders and Gambling

Other conditions that coexist with dual disorders include eating disorders and pathologic gambling. It may be helpful to refer patients to support groups that deal with these conditions. Eating disorders are more commonly diagnosed in women, and pathologic gambling is more commonly diagnosed in men.

Reassessment and Reassessment

The purposes of ongoing reassessments are: 1) to continue to refine prior diagnostic assessments, 2) to evaluate life adjustment in general, 3) to evaluate the effectiveness of treatment efforts for the dual disorders, and 4) to evaluate the discontinuation or continued use of medication and other treatments.

Persistently emerging and remitting problems should be addressed. For example, patients who chronically exhibit a negative disposition should be assessed for a personality disorder. Such patients may have a personality disorder with depressive features rather than a mood disorder.


Specific neuropsychological, psychological, educational, and vocational testing assessments should be performed when necessary and appropriate. These include testing for learning disorders, cognitive or literacy impairments, and personality disorders. These tests are more reliable and accurate when performed following several months of sobriety.

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.