5 keys to improve counseling for dual-diagnosis patients
An empathic approach can be effective when treating psychiatric patients with substance use disorders
WHICH DISORDER IS TREATED FIRST?
Three approaches are used for treating the coexisting problems of dual-diagnosis patients—sequential, parallel, and integrated.
Sequential treatment addresses the more acute disorder first; the other disorder receives greater attention later. This model is commonly used with hospital treatment, in which comparatively little attention would be paid to substance use in a patient who is acutely psychotic.
Parallel treatment addresses each disorder contemporaneously but in different settings (such as at a substance abuse program on Monday and a mental health center on Thursday).
One limitation of the sequential and parallel models is that psychiatric and substance abuse programs typically have different orientations. A lack of comprehensive assessment may leave the substance abuse or psychiatric disorder underdiagnosed, depending on the setting. Staff members may also project negative attitudes toward patients with psychiatric or substance use disorders if they know comparatively little about the diagnosis and treatment of the other type of disorder. Treatment in two settings also can lead to communication problems and differences of opinion among the treating clinicians.
Integrated treatment, in which both disorders are treated simultaneously in the same setting, has shown favorable outcomes in several initial studies.9 11 Different integrated treatment models have been described, which vary according to the psychiatric disorders’ nature and the treatment’s theoretical orientation. Integrated treatment strategies include:
- focusing on psychiatric and substance abuse issues simultaneously or in alternating sessions
- providing intense case management
- stressing the importance of medication compliance.12
COUNSELING PRINCIPLES
As mentioned, a careful history and thorough assessment are the keys to effectively treating the dually diagnosed patient.
Assess how the patient perceives the relationship between his substance use disorder and psychiatric symptoms. For example, ask, “What do you see as the relationship between your drinking and your depression, if any?”
As part of this process, explore both the immediate and long-term relationships between the two phenomena. For example, some patients will say that drinking offers them immediate relief from their depressive symptoms but exacerbates their depression the following day. Encouraging patients to look beyond the immediate—often positive—effects of their substance use may help them understand the negative consequences of continued use.
Review previous periods of recovery and relapse. For patients who have had substantial periods of recovery, it is important to acknowledge these successes and to ask in an upbeat and admiring way, “How did you do it?” This approach may remind patients of past successes and counterbalance their frequent feelings of discouragement and hopelessness.
Table 2
4 phases in treating the dually diagnosed patient
| Phase | Therapeutic goals |
|---|---|
| Engagement | Build an alliance Attract patient to treatment program |
| Persuasion | Convince engaged patient to accept longer-term, abstinence-based treatment |
| Active treatment | Help patient develop attitudes and techniques essential to maintain sobriety |
| Relapse prevention | Help patient maintain gains made in active treatment and cope with lapses/relapses should they occur |
To help clarify the relationship between coexisting disorders, ask patients about psychiatric symptoms they have experienced during periods of substance use and recovery. Taking a relapse history can help you and the patient identify decisions and behaviors he or she must avoid (such as stopping medication, failing to attend treatment, or engaging in high-risk activities as in going to bars).
PHASES OF TREATMENT
Four phases of dual-diagnosis treatment—engagement, persuasion, active treatment, and relapse prevention—have been described, along with their therapeutic goals (Table 2).13 Consider these phases when treating this population, even though most patients do not proceed through them in an orderly, linear fashion.
Engagement. At the onset, the therapist tries to build an alliance and begins to establish trust and credibility.
Persuasion involves helping the patient comprehend the need to seriously address his or her substance use. It is important during engagement and persuasion stages to be empathic, using reflective listening and validating techniques.
Helping the patient see the discrepancy between his or her long-term goals and current behavior can create the impetus for change. Linking the substance use and psychiatric symptoms and exploring their impact on each other may help the patient understand the problem.
Ambivalence and resistance are normal reactions to this process of change, so avoid arguing with the patient. Confrontation—long a common strategy in substance abuse treatment—is losing favor and is being supplanted in many cases by a more supportive, empathic approach.14 Indeed, patients with co-occurring psychiatric illness generally respond particularly poorly to confrontation.
Active treatment focuses on techniques to achieve abstinence, including alcohol and drug refusal skills, methods to deal with craving, and ways to recognize and avoid situations that present a high risk for relapse.
Relapse prevention reinforces gains made in previous stages. Here, the patient learns how to identify and deal with risky situations and how to handle a “slip” if it occurs.
