May/June 2007

Double Trouble — Helping Clients with Co-occurring Disorders
By John K. Smith, PhD, LCSW
Social Work Today
Vol. 7 No. 3 P. 18

Co-occuring mental health and substance abuse issues challenge clinicians to be properly trained to recognize both disorders and obtain the right treatment for clients.

Mike B. is a 32-year-old Caucasian male. His problems likely started when he was in his late teens. He occassionally drank alcohol and smoked pot with friends—not much to be concerned about at the time.

When he turned 17, Mike began to isolate himself. He became angry and depressed and spent most of his time alone in his room listening to music and playing his guitar. He imagined that he was a rock star and began to spend a great deal of time writing songs and music. His alcohol and pot use increased because he believed it enhanced his creativity.

Mike barely scraped by, graduating from high school mostly because his parents constantly pushed him. Usually their pushing would result in loud arguments, with Mike retreating to his room and his music. Mike’s parents were hard workers and away from home much of the time. They were concerned about their son but felt he was simply “going through a phase.”

Again, because of his parents, Mike held a series of menial jobs, which at least afforded him the money to buy alcohol and pot, of which his use had increased. Mike would spend hours in his room at night with his music, which he believed was inspired by God. He required little sleep.

His behavior became increasingly bizarre and one night, when he was in his early 20s, Mike was arrested and hospitalized on an emergency hold after he was found running naked down the street, singing incoherently. Due to the severity of his psychiatric condition, it took awhile to stabilize him on a medication regimen. During his stay, his drug and alcohol use was never assessed. Mike was asked a few questions in an evaluation, but he reported that he only occasionally used alcohol and smoked pot.

Upon his discharge from the hospital, he was referred to a mental health clinic for continuing care. In addition to a psychiatrist for medication management, Mike was assigned to a clinical social worker for ongoing therapy and case management.

What Happens Next?
What happens next depends on which social worker Mike is assigned to. If the social worker is trained in assessing and treating clients with co-occurring substance use and mental disorders, Mike will likely receive concurrent or integrated treatment for both problems. The social worker will assess the extent and level of Mike’s substance use and determine his readiness to change his behavior. This clinician will be trained in the practice of motivational interviewing to help engage Mike in the treatment process, realizing that his readiness and willingness to treat his mental illness may be different from his readiness to treat his substance use problem (Miller & Rollnick, 2002).

Once engaged, the social worker can begin to use active treatment techniques proven to enhance positive treatment outcomes for clients with co-occurring disorders, such as cognitive-behavioral therapy, disease management and education, social skills training, and referrals to specialized 12-step support groups (Smith, 2007; Minkoff, 2000).

Inadequately Trained?
Unfortunately, the majority of practicing clinicians, including social workers, have not received adequate training in the assessment and treatment of clients with substance use disorders, especially those with co-occurring disorders (i.e., dual diagnosis).

While there appears to be a growing trend toward integrated treatment of co-occurring disorders, there is still a lack of available training and clinical supervision to assist clinicians in honing and improving their knowledge and skills.The current body of literature recommends that all clinicians be cross-trained. Despite overwhelming evidence about the prevalence of co-occurring disorders, the mental health and substance abuse treatment systems have been slow to adapt or respond to the demand for better and more effective treatments for this population. Clinicians have been forced to provide treatment to clients with co-occurring mental illness and substance use disorders without having adequate training or resources to do so.

One study by Carey, Purnine, Maisto, Carey, and Simons (2000) showed that clinicians were treating clients with co-occurring disorders but often felt unprepared and inadequate in their knowledge and skill levels. Most clinical training programs and graduate programs in medicine, psychology, social work, addictions, and other related areas offer little, if any, training or course work in the assessment and treatment of co-occurring disorders. Hall, Amodeo , Shaffer, and Vander Bilt (2000) reported that social workers employed in substance abuse treatment facilities lacked adequate ongoing clinical supervision related to substance abuse treatment and felt a considerable need for further substance abuse training, especially in dual diagnosis.

High Prevalence of Dual Disorders
Why is this so important? No matter in what treatment setting social workers find themselves, they will encounter clients with co-occurring disorders. The most frequently cited study on the prevalence of comorbid substance abuse and severe mental illness is the Epidemiologic Catchment Area study (Regier et al, 1990). This study found that the prevalence of substance abuse in persons with a severe mental illness was between 30% and 60%. While the specific prevalence of each disorder is beyond the scope of this article, bipolar disorder and schizophrenia had the highest rates of comorbidity. Recent studies have shown the prevalence of physical and sexual abuse among substance abusers entering addiction treatment to be approximately 50%, and there are reports of as many as 75% of women in certain substance abuse treatment programs being diagnosed with posttraumatic stress disorder, primarily due to childhood sexual abuse or trauma related to their substance-abusing lifestyle (Pirard, Sharon, Kang, Angarita, & Gastfriend, 2005). Given the high prevalence of co-occurring substance abuse and mental disorders, especially in certain populations, it is safe to say that most social workers are encountering a high percentage of these clients in their caseloads. Yet, the majority are ill-prepared to adequately assess and treat them.

Since social workers are on the front lines in many treatment and service settings, they must be prepared to adequately assess clients who may have co-occurring disorders. Due to the high prevalence of these disorders among the populations most served by social workers, it is poor practice to be unprepared to identify, treat, and/or refer clients with comorbid conditions. While social workers do not all need to be experts in treating co-occurring disorders, they may be the best suited of all clinical professionals to provide the integrated care and constant case management required for successful treatment outcomes.

Basic Competencies
Not all social workers work directly in mental health or substance abuse treatment settings, yet almost all social workers work with clients who are at the highest risk for either or both problems. The following basic competencies should be present for all social workers in all settings:

• ability to accurately screen and assess for major mental illnesses;

• ability to accurately screen and assess for substance use disorders;

• familiarity with motivational interviewing and other client engagement tools;

• knowledge of how to access both mental health and substance abuse systems; and

• familiarity with local resources and referral sources, especially those with specialized programs for clients with co-occurring disorders.

For social workers in either the mental health or substance abuse treatment fields, the following skills and competencies must be present in addition to the ones listed previously:

• knowledge and experience with the substance abuse/addiction recovery process, including the disease concept and the 12-step model;

• familiarity with substance intoxication and withdrawal symptoms and the detoxification process;

• knowledge of stages of change and models of recovery;

• ability to conduct a mental status examination, including risk assessments;

• ability to develop differential diagnoses and familiarity with criteria and terminology in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision;

• ability to utilize cognitive-behavioral therapy concepts and techniques;

• familiarity with psychotropic medications and psychopharmacological management of mental illness and addiction;

• access to ongoing clinical supervision by experienced and qualified clinicians; and

• attitudinal and philosophical support for the special needs of clients with co-occurring disorders.

The last item may be one of the most important. It is critical for social workers to understand that traditional mental health and substance abuse treatment models and philosophies do not adequately address the needs of this population. For example, traditional substance abuse treatment programs are often confrontational, emotionally charged, and require total abstinence and a great deal of reading and writing. This type of setting would be very difficult for someone with schizophrenia due to the nature of the disorder. Also, traditional Alcoholics Anonymous meetings may or may not be supportive of members who are taking medication—a must for those with severe mental illness.

Flexibility and creativity are needed when designing treatment for clients with co-occurring disorders. The bulk of the research and literature supports the use of an integrated (simultaneous) program that treats the client vs. the disorder in a way that maximizes successful treatment of each one. For social workers, this often means implementing one of the basic values of “meeting clients where they are.” Once engaged, social workers can help advocate for and navigate clients through the obstacles created by artificial systems of care funded and designed to treat problems, not people.

Navigating Through Troubled Waters
Since the late ‘60s and early ‘70s, large “systems” of care have been developed to provide treatment for mental health and substance abuse problems. Large federal, state, and county bureaucracies have been established to oversee various funding streams and the provision of care for people with mental health or substance abuse problems.

Unfortunately, the word “or” tells the whole story. People were identified by their problem type as if their problems existed independently. Historically, these systems of care have been exclusionary and required people with both problems to seek treatment from at least two separate, and usually complex, entities.

It is not uncommon for individuals with co-occurring substance use and mental disorders to face major barriers to accessing treatment. For example, they may attempt to enter substance abuse treatment only to be told they cannot be treated for their substance abuse because they have a mental illness, which disqualifies them from treatment. If they enter through the mental health “door,” they are turned away because they have an active substance abuse problem that must be treated before they can receive mental health care. Our most vulnerable and fragile clients easily fall through the cracks and do not receive the necessary care. And clients who are already treatment resistant may find the obstacles to access an easy excuse for avoiding the treatment they desperately need.

Clients who are successful at getting through the door must attempt to navigate through two systems simultaneously—a daunting task for anyone but especially those with severe mental illness and substance abuse problems. This is called parallel treatment, and it is probably the most common way that clients with co-occurring disorders receive treatment. The problem with this method of treatment (bureaucratic red tape aside) is that the mental health system and substance abuse system often have different approaches and philosophies of treatment.

Often these approaches are contradictory and contraindicated for clients. For example, some substance abuse treatment programs are not supportive of using psychotropic medications, while mental health providers may be overly reliant on medications. Psychotropic medications are a necessity for treating and stabilizing mental illness symptoms that may be exacerbated or reduced by the use of drugs and alcohol. In contrast, the use of drugs and alcohol may negate or potentiate the effects of the psychotropic medication and must be minimized or eliminated for treatment to be effective.

The real issue is the coordination of care within and between providers and systems of care. It is difficult at best to coordinate care because there is a lack of communication between the two systems and the providers within these systems. Because of the different philosophies and practices, coordinated care requires someone who can assist the client in navigating through these systems and ensure that treatment is working for the client rather than against him or her. Case management of these clients is ideally suited for social workers trained in both mental health and substance abuse treatment who can also advocate for their clients.

Ideally, the best and most effective treatment for co-occurring disorders is integrated treatment (Smith, 2007). Integrated treatment involves concurrent treatment for both disorders in one setting, usually with a multidisciplinary team of providers trained in the special needs of these clients. While the literature continues to support integrated treatment as the most effective form of treatment, there continues to be large-scale resistance from the systemic level to the provider level when it comes to implementation. Social workers have a unique opportunity to fill a major need by preparing to deal with these clients and stepping into treatment and case management roles that are becoming more prevalent.

What Next?
Practitioners and students wishing for more information on this topic may go to the Treatment Improvement Exchange Web site for access to several Treatment Improvement Protocols and Technical Assistance Publications (www.treatment.org/topics/dual_publications.html). An increasing number of workshops and trainings on these topics are slowly but surely becoming available.

Schools of social work and other similar professions need to incorporate coursework in the assessment and treatment of co-occurring disorders. Current practitioners should read the literature and attend continuing education workshops and courses to get the current best practices for assessing and treating co-occurring disorders.

— John K. Smith, PhD, LCSW, is a licensed psychotherapist with more than 25 years of experience in the mental health and chemical dependency fields and is program administrator for the Dual Diagnosis Day Treatment Program at Doctor’s Hospital of West Covina, CA. He is also a professor of alcohol and drug counseling at Mt. San Antonio College in Walnut, CA, and is the author of the recently published book Co-occurring Substance Abuse and Mental Disorders: A Practitioner’s Guide.

References

Carey, K.B., Purnine, D.M., Maisto, S.A., Carey, M.P., & Simons, J.S. (2000). Treating substance abuse in the context of severe and persistent mental illness: Clinician’s perspectives. Journal of Substance Abuse Treatment, 19(2),189–198.

Hall, M.N., Amodeo, M., Shaffer, H.J.B., Vander Bilt, J. (2000). Social workers employed in substance abuse treatment agencies: A training needs assessment. Soc Work, Mar; 45(2),141-155.

Minkoff, K. (2000). An integrated model for the management of co–occurring psychiatric and substance abuse disorders in managed-care systems. Disease Management and Health Outcomes, 8(5),251–257.

Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing (2nd Ed.): Preparing People for Change, New York: The Guilford Press.

Pirard, S., Sharon, E., Kang, S.K., Angarita, G.A., Gastfriend, D.R. (2005). Prevalence of physical and sexual abuse among substance abuse patients and impact on treatment outcomes. Drug and Alcohol Depen, 4;78(1),57-64.

Regier, D.A., Farmer, M.E., Rae, D.S., Locke, B.Z. Keith, S.J., Judd, L.L., & Goodwin, F.K. (1990). Co–morbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiological Catchment Area (ECA) study. JAMA, 264, 2511–2518.

Smith, J. (2007). Co-occurring Substance Abuse and Mental Disorders: A Practitioner’s Guide. New York: Rowman and Littlefield.