Expert answer:Dual Diagnosis
Expert answer:Application: Dual DiagnosisMany clients who are diagnosed with substance abuse and addiction disorders also exhibit a psychological disorder. The prevalence and complexity of this phenomenon, known as a dual diagnosis, make it imperative that you, as a counselor, know how to properly diagnose and work with substance abuse clients who also exhibit psychological disorders.
For this Application, you will examine the complexities of dual diagnosis in relation to a specific case.
To prepare for this assignment:Review this week’s Learning Resources, focusing on the client symptoms and characteristics that may indicate a dual diagnosis.Consider how the symptoms of substance abuse and those of psychological disorders make dual diagnosis particularly complex.Review the following case study: Jerome.Consider how the case study reflects the complexities of dual diagnosis.The assignment: (1–2 pages)Analyze the complexity of dual diagnosis as it relates to the case study.Explain how specific symptoms illustrated by the client indicate more than one disorder and make diagnosis difficult.Provide specific examples as well as evidence from the Learning Resources to support your ideas.Support your Application assignment with specific references to all resources used in its preparation. You are asked to provide a reference list only for those resources not included in the Learning Resources for this course.
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MS PSYC 8728/COUN 8728
Substance Abuse Counseling
Case Study
Jerome
Jerome is a 48-year-old gay-identified African American male who is seeking housing
services at the state facility at which you work. Jerome has a long history of
homelessness, a 20-year addiction to crack cocaine, and a history of minor arrests. He
has supported himself primarily by repairing old, discarded bicycles and selling them.
When Jerome comes to the facility, he states he has not used crack for three days.
During the initial interview, he does not maintain eye contact, constantly moves and shifts
in his seat, and uses a very unique sentence structure that often derails: “I am on top of
this whole planet, and it’s hot! I feel like…you ever eat yogurt?” He describes hearing
voices that direct him to deliver “the message of the good” to people he meets, and uses
religious references in a number of statements about daily living.
Jerome expresses his desire to stop using crack, but his concern is that “when I stop, the
Devil comes after me.” You learn from Jerome’s caseworker that Jerome has had
connections to a street gang from whom he buys crack, and that a large part of the
reason he is seeking housing at your facility is for safety because of some trouble he has
gotten into with a gang member.
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Is Integrated Treatment of
Co-Occurring Disorders More Effective
than Nonintegrated Treatment?
Brian E. Bride, Samuel A. MacMaster, and Lisa Webb-Robins
The integrated treatment model has been touted as more effective than standard
approaches to treating individuals with co-occurring substance use and mental health
disorders. However, most studies on the effectiveness of integrated treatment lack control or comparison groups, limiting the conclusions that can be drawn. This article
reviews studies that compare the effectiveness of integrated and nonintegrated treatment of co-occurring mental and substance use disorders on substance use, mental
health, and community stability outcomes. Additional research is clearly needed to
determine whether integrated treatment models for co-occurring disorders are, in fact,
more effective than nonintegrated models.
Key words: integrated treatment; co-occurring disorders; dual diagnosis; substance
abuse; mental health
Introduction
The co-occurrence of substance use and mental disorders is highly prevalent
both in the general population and in clinical samples (Kessler et al., 1996). Epidemiological studies suggest that nearly half of the people with a substance use
disorder have a co-occurring mental disorder, while as many as 40% of the people
with a mental disorder have a co-occurring substance use disorder (Kessler et al.,
1996; Regier et al., 1990). In clinical samples of psychiatric populations, 30% of
those with depressive disorders, 50% with bipolar disorders, and 50% with psychotic disorders have substance use disorders (Miller, 1994a). Among people with
an alcohol use disorder, 37% have a comorbid mental disorder, while 53% of those
with drug use disorders report another lifetime mental disorder (Regier et al.).
Brian E. Bride, Ph.D., MSW, is assistant professor at the School of Social Work, University of Georgia, Athens. Samuel A. MacMaster, Ph.D., MSSW, is assistant professor at the College of Social
Work, University of Tennessee, Knoxville. Lisa Webb-Robins, Ph.D., is director of research and
planning for the Tennessee Department of Economic and Community Planning, Nashville.
© 2006 Lyceum Books, Inc., Best Practices in Mental Health, Vol. 2, No. 2, Summer 2006
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Recent epidemiological studies have demonstrated similar rates of co-occurrence
(Kessler, Chiu, Demler, & Walters, 2005; Weaver et al., 2003). People with cooccurring disorders typically have poorer treatment outcomes than people who
have only one disorder, including more frequent psychiatric re-hospitalizations
(Caton, Wyatt, Felix, Grunberg, & Dominguez, 1993; Drake, Osher, & Wallach,
1989; Haywood et al., 1995), more severe psychiatric symptoms (Carey, Carey, &
Meisler, 1991; Drake, 1989; Osher et al., 1994), higher rates of relapse (Swofford,
Kasckow, Scheller-Gilkey, & Indrbitzin, 1996), and housing instability and homelessness (Drake et al., 1989; Drake & Wallach, 1989; Osher et al.).
Historically, major mental illness and substance abuse have been treated in separate service systems with differing and sometimes contradictory philosophical
orientations in what has been called the serial or sequential treatment model; that
is, individuals are treated first by one system (either substance abuse or mental
health) and then by the other (Center for Substance Abuse Treatment [CSAT]
1994; Miller, 1994a, 1994b). Typically, a patient is stabilized in an inpatient or
outpatient psychiatric unit and then transferred to a separate chemical dependency unit. The staffs treating each disorder often fail to communicate or cooperate with each other in the individual’s treatment, and they may be mutually
antagonistic toward each other (Miller, 1994a). Further, the staffs from both sides
often are neither knowledgeable, nor skilled in the other treatment approach,
resulting in a fragmented treatment experience (Miller, 1994b).
The parallel treatment model is a second approach to treating mental health
and substance use disorders. In the parallel approach, psychiatric and addiction
treatments are provided concurrently, but in different settings and by different
staff members. While the parallel model improves upon the serial model by providing concurrent treatment, it also shares the limitation of relying upon separate
service systems and treatment philosophies that are often in conflict. In both the
serial and parallel treatment models, knowledge and skill deficits of service
providers serve to perpetuate a focus on one type of disorder over the other (Pulice,
Lyman, & McCormick, 1994). Further, the problem is compounded by philosophical differences between the two fields as to what constitutes appropriate treatment (Young & Grella, 1998). These philosophical differences have historically
included a reliance on peer counselors, spiritual recovery, and a self-help approach
within a recovery model in the addictions field, as opposed to a medical model with
the use of medications, scientifically based treatment approaches, and continuous
case management within the mental health field. As such, these treatment
approaches inadvertently confound and compartmentalize conditions that are
inseparable (Osher, 1996).
In response to these limitations, a number of experts have promoted an integrated treatment (IT) model. This model combines methods and skills derived from
both psychiatric and addiction treatment practices to treat dually diagnosed individuals in a single setting with a single staff (Drake, Yovetich, Bebout, Harris, &
McHugo, 1997; Ho et al., 1999; Minkoff, 1989; Osher, 1996). Clinicians in integrated treatment programs are cross-trained in both mental health and substance
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abuse. Thus, the diagnosis and treatment of both psychiatric and substance use
disorders can be implemented simultaneously, minimizing conflicts between the
two approaches (CSAT, 1994; Minkoff). Individuals participate in a single program in which their mental disorder and substance use disorder are treated by the
same clinicians—clinicians who are trained in assessment and treatment strategies for both problems (Drake, Mercer-McFadden, Mueser, McHugo, & Bond,
1998).
The IT model has been touted as a more effective approach to treating people
with co-occurring disorders than the serial and parallel treatment models (CSAT,
1994; Drake, Mueser, Brunette, & McHugo, 2004; Minkoff, 1989; Mueser, Bellak,
& Blanchard, 1992). However, Drake, Mercer-McFadden, et al. (1998) reviewed
36 research studies on the effectiveness of IT models and concluded that the addition of dual-disorders groups to traditional services, short-term IT in controlled
settings and demonstration projects with high-risk groups (Drake, McHugo, et al.,
1998; Mercer-McFadden et al., 1997; Mueser & Noordsy, 1996) failed to demonstrate positive outcomes. In reviewing studies of comprehensive integrated programs, they found more encouraging evidence of the effectiveness of IT for cooccurring disorders. Specifically, they noted that comprehensive IT may result in
“significant reductions of substance abuse and, in some cases, in substantial rates
of remission, as well as reductions in hospital use and/or improvements in other
outcomes” (Drake, Mercer-McFadden, et al., 1998, p. 601).
Given these findings, it is surprising that IT has become accepted in most circles
as more effective than standard treatment (ST) models. Drake, Mercer-McFadden,
et al. (1998) point out that the disappointing results may be a result of the limitations of many of the existing studies. Specifically, the majority of studies included
in their review lacked control or comparison groups, thereby limiting conclusions
regarding the differential effectiveness of IT as compared to nonintegrated treatment. In addition, many of the studies were limited by small sample sizes, increasing the probability of Type II errors. As such, it is possible that an examination of
studies with more methodological rigor, specifically those implementing comparison groups and with a sufficient sample size, would provide more positive results.
To that end, this article critically reviews studies that compare the effectiveness of
integrated and nonintegrated treatment of co-occurring mental and substance
use disorders in substance use, mental health, and community stability outcomes.
Methodology
Electronic searches were conducted of PsycINFO and Medline databases
to identify articles published in refereed journals through June 2005 that examined the effectiveness of IT of co-occurring mental health and substance use disorders as compared to nonintegrated treatment. A start date was not specified
as we wished to identify all potential studies regardless of when they were conducted. The following key words were used in the search: dual diagnosis, integrated treatment, substance abuse and mental illness, co-morbidity, and
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co-occurring disorders. In addition, the text and bibliographies of identified articles were reviewed for additional references that were not captured by the computerized searches.
To be included in the review, articles had to meet three criteria. First, articles
had to report on experimental or quasi-experimental designs that compared integrated treatment models with nonintegrated models. Thus, studies that compared
different models or modalities of IT without a nonintegrated comparison group
were excluded, as were those that simply reported outcomes of an integrated program, but lacked a comparison group. Second, the majority of subjects had to
meet the criteria for a serious mental disorder, primarily schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder, in addition to a substance use disorder. Third, included studies were required to have a sample size of
100 or greater. A limitation cited by all prior reviews is that a significant number
of studies are limited by small sample sizes. Assuming a medium effect size and a
significance level of .05, a sample size greater than or equal to 100 ensures that
included studies will have a power of .86 or higher (Cohen, 1988). A total of four
empirical studies comparing integrated treatment of individuals with co-occurring disorders to nonintegrated treatment met the inclusion criteria, two of which
(Burnam et al., 1995; Drake et al., 1997) were included in the earlier review by
Drake, Mercer-McFadden, et al. (1998).
Results
Description of Reviewed Studies
In the first study, Burnam et al. (1995) randomly assigned 276 homeless,
dually diagnosed individuals to one of three conditions: a residential social model
treatment program, a nonresidential social model program, and a control group.
According to the authors, the social model approach combines elements of substance abuse recovery and mental illness management in an effort to assist clients
in developing an independent life in the community through abstinence and by
enhancing their social and vocational abilities. Common activities of both the residential and nonresidential social model programs included curriculum-based
groups, 12-step programs including community-based Alcoholics Anonymous
and Narcotics Anonymous meetings, process-oriented groups, individual counseling and case management, psychiatric consultation and medication management, and general community activities. Both the residential and the nonresidential social model programs consisted of a 3-month intensive phase followed by
three months during which graduates were encouraged to continue to participate
in nonresidential program activities. The control group received no special intervention, but was free to access other available community services in what can be
considered a de facto parallel treatment model. Outcome variables associated with
substance use, severity of mental illness symptoms, and housing status were collected at 3-, 6-, and 9-month follow-ups.
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In the second study, Drake and colleagues (1997) used a quasi-experimental,
non-equivalent comparison group design to compare IT with ST for 217 homeless, dually diagnosed adults over an 18-month period. People in the IT group
received integrated mental health treatment, substance abuse counseling, and
housing services from one of two multidisciplinary teams within a private, nonprofit mental health center. The treatment model was based on a manual developed by the authors, and extensive training and monitoring were provided to
ensure model adherence. Both treatment teams relied heavily on behavioral substance abuse treatment methods, although one emphasized cognitive/behavioral
approaches, while the other emphasized social network approaches. Individuals in
the ST group received services through multiple agencies in the existing housing,
substance abuse, self-help, and community mental health system in a parallel
treatment model. According to the investigators, the key difference between the
two groups was the level of integration of services.
The third study was a three-year, randomized, clinical trial of 223 dually diagnosed individuals that compared integrated mental health and substance abuse
treatment within an assertive community treatment (ACT) approach to the treatment provided within a standard case management (SCM) approach (Drake,
McHugo, et al., 1998). Both approaches integrated substance abuse treatment
with mental health treatment. Both also offered similar features such as a team
approach, services provided in the community, engagement of the client’s support
system, and a focus on co-occurring disorders. However, ACT teams provided
more services directly, had smaller caseloads, greater intensity of services, dual
disorders as a specialization, more of a team approach, more individualized substance abuse treatment, and thus more integrated services than the SCM teams.
Indeed, other authors have determined that ACT is more integrated than other
standard case management approaches (Burns & Santos, 1995).
In the fourth study, De Leon, Sacks, Staines, and McKendrick (2000) sequentially assigned 342 homeless adults with co-occurring substance use and mental
disorders to one of three groups: a moderate intensity, modified therapeutic community (modified TC1); a low intensity, modified therapeutic community (modified TC2); or treatment as usual (TAU) group. Modified TC1 was similar to standard therapeutic communities in structure, process, and interventions, but was
adapted to the psychiatric symptoms, cognitive impairments, and reduced level of
functioning often found in people with co-occurring disorders. Thus, compared to
standard therapeutic communities, modified TC1 provided increased flexibility,
less intensity, and greater individualization in a 12-month program. Modified TC2
was similar in planned duration of stay, stages, and array of interventions to modified TC1. However, modified TC2 differed from modified TC1 in several ways:
clients were allowed greater freedom to come and go early in treatment, clients left
the facility to attend a day treatment program in the community, peer responsibility was reduced in terms of duties that clients and staff shared for operating the
facility, staff provided more direct assistance in running program interventions
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and directing client activities, and fewer activities and shorter interactions were
used. Thus, modified TC2 placed still fewer demands on clients and was even more
flexible in accommodating individual needs and deficiencies than modified TC1.
Services received by the TAU group were fewer, less specific to the needs of people
with co-occurring disorders, not as well organized, and less related to a cohesive
perspective and approach than those received by the modified TC groups.
Results of Reviewed Studies
Sample characteristics Table 1 presents the sample characteristics for each study
as reported in the original publications. Across the four studies included in this
review, the mean sample age was similar, ranging from 34 to 37. In three studies,
the sample was primarily male, ranging from 72% to 84% male, with only Drake
et al. (1997) reporting a primarily female (66.4%) sample. The reported ethnicity
Table 1
Sample Characteristics of Reviewed Studies
Burnam et al.
Drake et al.
De Leon et al.
(1997)
Drake,
McHugo, et al.
(1998)
(1995)
Age (mean years)
37a
35.7
34.0
35.1
Gender (%)
Female
Male
16a
84a
66.4
33.6
25.6
74.4
28.0
72.0
Ethnicity (%)
African American
Caucasian
Other
28a
58a
14a
89.4
9.7
0.9
96.4
3.6
73.0
11.0
16.0
Education (%)
< 12 years
12 years
> 12 years
28a
34a
38a
45.2
49.3
5.5
36.9
42.8
20.3
58.0
23.0
20.0
Marital Status (%)
Never married
Married
Previously married
49a
6a
45a
59.4
2.3
38.2
61.0
10.7
28.3
79.0
0.0
21.0
7a
38a
53.4
22.4
24.2
37.8
12.0
16.6
30.4
3.2
100b.0
2.7
100.0b
Psychiatric Diagnosis (%)
Schizophrenia
Schizoaffective
Bipolar Disorder
Major Depression
Other
Homeless (%)
55a
100a
100.0
(2000)
aRepresents “major affective disorders.” Authors did not differentiate between bipolar disorder and major depression.
bAuthors did not provide statistics on specific disorders.
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of sample participants was widely variable across the studies, with between 0%
and 89.4% African American, 9.7% and 96.4 % Caucasian, and 0.9% and 16%
other ethnic groups. The educational level of the samples also varied across studies, with 28% to 58% being high school dropouts, 23% and 49.3% having a high
school diploma or GED, and 5.5% to 38% having at least some college. Most of the
sample participants either had never married (49% to 79%) or were divorced or
widowed (21% to 45%). Only three studies reported specific mental health diagnoses. Burnam at al. (1995) reported the fewest diagnoses of schizophrenia (7%)
and the most diagnoses of affective disorders (bipolar disorder and major depressive disorder; 55%), whereas Drake et al. (1997) reported the highest proportion
of schizophrenia diagnoses (53.4%). Last, the sample populations in the three
studies were entirely of homeless people, with the fourth study (Drake, McHugo, et
al., 1998) reporting almost no (2.7%) homeless people.
Substance use outcomes A consistent finding across studies was that participants
improved on various substance use outcomes over t …
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