Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness

A Handbook for Mental Health Professionals

Alan S. Bellack, Melanie E. Bennett, Jean S. Gearon

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9781138411449
• eBook ISBN: 9781135927233
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

The correlation between schizophrenia and substance abuse in psychology is recognized as a growing issue, yet it is one that many practitioners are often ill-prepared to address. Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness addresses the specific challenges faced by the clinician treating individuals with co-occurring schizophrenia and substance abuse disorders. Designed as a treatment manual for mental health professionals, the book incorporates various treatment components, from motivational interviewing and social skills training to education, problem solving, and relapse prevention.

The book presents clearly established guidelines for these treatment modes and utilizes both case examples and fictional situations to present a practical, hands-on approach. Readers will profit directly from the lessons in the book, which offers the clinician an invaluable model from which to base a treatment plan.

Part I

Chapter 1

INTRODUCTION TO TREATING PEOPLE WITH DUAL DISORDERS

Drug and alcohol abuse by people with severe and persistent mental illness (SPMI) is one of the most significant problems facing the public mental health system. Referred to variously as people with dual disorders or dual diagnosis, mentally ill chemical abusers, and individuals with co-occurring psychiatric and substance disorders, these patients pose major problems for themselves, their families, clinicians, and the mental health system. Lifetime prevalence of substance abuse was assessed at 48% for schizophrenia and 56% for bipolar disorder in the Epidemiological Catchment Area study (Regier et al., 1990), and estimates of current abuse for the SPMI population range as high as 65% (Mueser, Bennett, & Kushner, 1995). Rates of abuse are likely to be even higher among impoverished patients living in inner city areas where drug use is widespread. Substance use disorders (SUDs) in people with SPMI begins early in the course of illness, and has a profound impact on almost every area of the person’s functioning and clinical care. People with SPMI and SUDs show more severe symptoms of mental illness, more frequent hospitalizations, more frequent relapses, and a poorer course of illness than do those with a single diagnosis. They also have higher rates of violence, suicide, and homelessness. They manifest higher rates of incarceration, greater rates of service utilization and cost of health care, poorer treatment adherence, and treatment outcome. People with schizophrenia are now one of the highest risk groups for HIV, and there are ample data to indicate that substance use substantially increases the likelihood of unsafe sex practices (Carey, Carey, & Kalichman, 1997), the primary source of infection in this population. Women with schizophrenia and comorbid substance use disorders are at substantial risk of being raped and physically abused (Gearon, Kaltman, Brown, & Bellack, 2003). Substance use also impairs information processing, which is particularly problematic for people with schizophrenia, given the range of cognitive deficits characterizing the disorder (Tracy, Josiassen, & Bellack, 1995).

The toxic effects of psychoactive substances in individuals with schizophrenia and bipolar disorder may be present even at levels of use that may not be problematic in the general population. Although people with SPMI may abuse lower quantities of drugs, they are more likely to experience negative effects as a result of even moderate use. There is evidence to suggest that they are more sensitive to lower doses of drugs (supersensitivity model). For example, in challenge studies, patients with schizophrenia have been shown to be highly sensitive to low doses of amphetamine that produce minimal response in controls (Lieberman, Kane, & Alvir, 1987). Other studies have shown that people with SPMI can experience negative clinical effects, such as relapse, following self-administered use of small quantities of alcohol or drugs (Mueser, Drake, & Wallach, 1998).

Why do people with SPMI use street drugs if the consequences are so severe? It is widely assumed that they use substances as a form of self-medication: to reduce symptoms of mental illness and to alleviate side effects of medications, especially the sedating effects of many neuroleptics. However, the data suggest that substance abuse by many people with SPMI is motivated by the same factors that drive excessive use of harmful substances in less impaired populations: negative affective states, interpersonal conflict, and social pressures. Empirical data do not document a consistent relationship between substance use and specific forms of symptomatology. Alcohol is the most commonly abused substance by people with SPMI, as well as in the general population. Preference for street drugs varies over time and as a function of the demographic characteristics of the sample. For example, Mueser, Yarnold, and Bellack (1992) reported that between 1983 and 1986 cannabis was the most commonly abused illicit drug among people with schizophrenia, whereas between 1986 and 1990 cocaine became the most popular drug, a change in pattern similar to that in the general population. For many people with SPMI, availability of substances appears to be more relevant than the specific neurological effects. Poly-drug abuse is also common, with availability determining which drugs are used when.

In addition, the pattern of use appears to be somewhat intermittent or adventitious, rather than a persistent daily activity. For example, in our research, carefully diagnosed subjects meeting DSM-IV criteria for drug dependence reported using drugs on about nine days each month, primarily on weekends and when they received their benefit checks (American Psychiatric Association, 1994). Many dual disordered people also seem to be able to go for periods of time (weeks or months) with little or no drug use, and then resume regular use. Relatively few of these individuals fit the profile of the daily (or almost daily) cocaine or heroin abuser, whose daily activity is focused on how to get money and access drugs. Given this pattern of intermittent drug use, people with dual disorders generally do not report extreme cravings or withdrawal symptoms. Rather, they seem to be very much affected by social and environmental cues, especially including people with whom they often use drugs, and time (e.g., the week before benefit checks arrive). It is also worth noting that many people with SPMI do not have enough money to maintain an expensive drug habit. They often access drugs from friends and family. Some dually disordered women exchange sex for drugs, but it appears as if they are more likely to be taken advantage of than to be active sex workers.

Treatment of Substance Abuse in People with SPMI

There is extensive literature on the treatment of dual disordered SPMI patients (Bellack & Gearon, 1998; Drake, Mueser, Brunette, & McHugo, 2004), and there is a broad consensus on a number of elements required for effective treatment, including: There should be integration of both psychiatric and substance abuse treatment (Mueser, Noordsy, Drake, & Fox, 2003). The traditional service models in which substance abuse and psychiatric (mental health) treatment are implemented by distinct clinical teams with different funding streams does not work for these very impaired individuals. They are unable to coordinate services between two distinct clinical systems, and they need a consistent message from all relevant clinicians: drug use is harmful. We will discuss some models of integrated care in chapter 13). Treatment should be conceptualized as an ongoing process in which motivation to reduce substance use waxes and wanes (Bellack & DiClemente, 1999). BTSAS is designed to be a six-month program because the literature suggests that this is a reasonable minimum time frame. However, that duration was partly determined by the exigencies of our NIH grants; a longer duration will often be desirable or necessary. An extended treatment period is required for two reasons. First, it is necessary for the participants to experience both successes and failures in reducing drug use. Failures, in particular, provide an opportunity for the therapists to teach the person how to cope with lapses, and how to prevent lapses (an occasional bad day or weekend) from turning into relapses (i.e., full return to pretreatment rates of use). Second, motivation to reduce drug use waxes and wanes over time. It is important to have the person engaged in group when motivation is waning, so the group can provide a motivational boost, and so the person can learn how to cope with periods of low motivation and strong urges to use drugs. Third, a harm reduction model is more appropriate than an abstinence model, especially during the early stages of treatment when the patient has uncertain motivation to change (Carey, Carey, Maisto, & Purnine 2002). The term harm reduction refers to an approach that values anything that reduces risk or harm associated with drug use. As indicated above, people with dual disorders are at risk for a host of adverse consequences, ranging from psychiatric relapse to sexual abuse to HIV infection. Any day that they avoid drugs decreases the risk of those adverse consequences. Of course, abstinence is the most appropriate long term goal for everyone. But, the evidence suggests that if abstinence (or a commitment to become abstinent immediately) is a precondition to entering treatment most dual disordered persons will not enroll. Further, if the clinician persistently and aggressively promotes abstinence and is critical of efforts to cut down use, the attrition rate is very high. Thus, the program should promote reduced drug use in the short term, and keep abstinence in mind as a long term goal.

While there is widespread agreement that integrated treatment employing a psychoeducational approach that is sensitive to motivational level is the best treatment strategy (i.e., a general structure for delivering treatment), there is a dearth of empirical data on effective techniques for producing change (i.e., specific treatment procedures). This literature has been surveyed in three recent reviews, each of which used somewhat different criteria for identifying and evaluating clinical trials. Drake, Mueser et al. (2004) found 16 studies of outpatient treatment, 4 using quasi-experimental designs and 12 using experimental designs. Nine studies tested brief interventions (1 to several sessions) to increase engagement or motivation to change. Seven studies evaluated integrated treatment (primarily some form of assertive case management), of which only three tested the effects of a specific substance abuse intervention. Jerrell and Ridgely (1995) compared a 12-step program, behavioral skills training, and intensive case management. While each of the latter two interventions was more effective than the 12-step condition on a variety of outcome domains, the effects on substance use were quite modest. Barrowclough et al. (2001) compared a multimodal intervention that included cognitive behavioral therapy and family psychoeducation to routine care in a study conducted in the United Kingdom. They found a modest advantage for the experimental treatment initially and at an 18-month follow-up (Haddock et al., 2003). While Drake, Mueser et al. (2004) were generally positive about the effectiveness of available treatments, they concluded that, “As yet there is little evidence for any specific approach to treatment….”

Dumaine (2003) and Ley, Jeffery, McLaren, and Siegfried (2003), in an analysis done for the Co-chrane Review, each found only six randomized trials of psychosocial treatments for dually disordered clients. While still advocating the use of integrated, psychoeducational interventions, Dumaine (2003) reported that the largest effect size, which was for intensive case management without a specific psycho-educational component, was only 0.35, and the largest effect size for a specific psychosocial treatment procedure was only 0.25. In the least optimistic view of the literature, Ley et al. (2003) concluded that: There is no clear evidence supporting an advantage of any type of substance misuse program for those with serious mental illness over the value of standard care, and no one program is clearly superior to another. These reviews were each written before the most recent outcome data for BTSAS became available. As indicated below and described more fully in a paper published in the Archives of General Psychiatry (Bellack, Bennett, Georon, Brown, & Yang, 2006), BTSAS may be the most promising approach developed to date.

Why is it So Difficult to Reduce Drug Use by People with SPMI?

An extensive body of research on substance abuse and addiction in the general population indicates that critical factors in abstinence and controlled use of addictive substances include high levels of motivation to quit, the ability to exert self-control in the face of temptation (urges), cognitive and behavioral coping skills, and social support or social pressure. Unfortunately, people with SPMI, especially those with schizophrenia, often have limitations in each of these areas. First, several factors can be expected to diminish motivation in people with schizophrenia. They frequently suffer from some degree of generalized avolition (lack of motivation or drive) and anergia (lack of energy or initiative) as a function of neurological dysfunction (hypoactivity of the dorsolateral prefrontal cortex), medication side effects, or other social, psychological, and biological factors that contribute to negative symptoms. Thus, they may lack the internal drive to initiate the complex behavioral routines required for abstinence. This hypothesis was supported in a survey of dually diagnosed persons, which found that depending on the substance abused, as many as 41% had little motivation to reduce their substance use and only 52% were participating in substance abuse treatment. Another negative symptom, anhedonia, may compromise the experience of positive emotions, thereby limiting the ability to experience pleasure and positive reinforcement in the absence of substance use and restricting the appraisal of the advantages of reduced substance use. While people with other diagnoses (e.g., bipolar disorder) have a different neurobiology, they may also suffer from secondary negative symptoms (e.g., negative symptoms driven by medication side effects, cumulative effect from failure experiences and frustration in life).

A second issue is the profound and pervasive cognitive impairment that characterizes schizophrenia and is often present in bipolar disorder. Research since the mid-1990s indicates that persons with schizophrenia have prominent cognitive impairments, including deficits in attention, memory, and higher level cognitive processes, such as abstract reasoning, maintenance of set, the ability to integrate situational context or previous experience into ongoing processing, and other “executive” functions. They have been shown to have profound deficits in problem solving ability on both neuropsychological tests (e.g., the Wisconsin Card Sorting Test), and on more applied measures of social judgment. There are several lines of evidence, which suggest that cognitive impairment is largely (but not completely) independent of symptoms, and that many of these higher level deficits may result from a subtle neurodevelopmental anomaly reflected in frontal-temporal lobe dysfunction. Moreover, cognitive performance deficits are not substantially ameliorated by treatment with typical antipsychotic medications.

These higher-level cognitive deficits would be expected to make it very difficult for people with schizophrenia to engage in the complex processes thought to be necessary for self-directed behavior change. They may have difficulty engaging in self-reflection or in evaluating previous experiences to formulate realistic self-efficacy appraisals. Deficits in the ability to draw connections between past experience and current stimuli may impede the ability to relate their substance use to negative consequences over time, and modify decisional balance accordingly. Deficits in problem solving capacity and abstract reasoning may impede the ability to evaluate the pros and cons of substance use or formulate realistic goals. Problems in memory and attention may also make it difficult for people with SPMI to sustain focus on goal-directed behavior over time.

Third, people with schizophrenia have marked social impairment. They are often unable to fulfill basic social roles, they have difficulty initiating and maintaining conversations, and they frequently are unable to achieve goals or have their needs met in situations requiring social interaction. These deficits are moderately correlated with symptomatology, especially during acute phases of illness, but the disruptive effects of acute symptoms do not account for the panoply of interpersonal deficits exhibited by most of these patients. The precursors of adult social disability can often be discerned in childhood, and may be associated with early problems in attention. This pattern of social impairment would leave people with schizophrenia who abuse drugs vulnerable in a number of ways: they would have difficulty developing social relationships with individuals who do not use drugs; would have difficulty resisting social pressure to use; and they would have difficulty developing the social support system needed to reduce use.

Behavioral Treatment for Substance Abuse by People with SPMI (BTSAS)

BTSAS is an innovative behavioral treatment to address illicit drug use among people with SPMI. We have developed BTSAS over a 10-year period with the support of a series of grants from the National Institute of Drug Abuse (NIDA). BTSAS was specifically designed to address the special needs of dual disordered persons, especially those with schizophrenia. It will be apparent to experienced clinicians that many of the elements of BTSAS are similar to techniques widely used in interventions with less impaired populations of substance abusers. However, we have systematically modified the techniques to accommodate to people with SPMI. Notably, a variety of strategies and tactics are employed to address cognitive impairment, and the typical pattern of low and variable motivation.

BTSAS contains six integrated components:(1) motivational interviewing to enhance motivation to reduce use; (2) structured goal setting to identify realistic, short-term goals for decreased substance use; (3) a urinalysis contingency designed to enhance motivation to change and increase the salience of goals; (4) social skills and drug refusal skills training to teach participants how to refuse social pressure to use substances, and to provide success experiences that can increase self-efficacy for change; (5) education about the reasons for substance use and the particular dangers of substance use for people with SPMI, in order to shift the decisional balance towards decreased use; and (6) relapse prevention training that focuses on behavioral skills for coping with urges and dealing with high risk situations and lapses. Each of these components will be described in more detail in later chapters of this book.

Several steps are taken in consideration of cognitive deficits. Sessions are highly structured, and there is a strong emphasis on behavioral rehearsal. The material taught is broken down into small units. Complex social repertoires required for making friends and refusing substances are divided into component elements such as maintaining eye contact and how to say, “No.” Patients are first taught to perform the elements, and then gradually learn to smoothly combine them. The intervention emphasizes overlearning of a few specific and relatively narrow skills that can be used automatically, thereby minimizing the cognitive load for decision making during stressful interactions. Extensive use is made of learning aides, including handouts and flip charts, to reduce the requirements on memory and attention. Participants are prompted as many times as necessary and there is also extensive repetition within and across sessions. Participants repeatedly rehearse both behavioral skills (e.g., refusing unreasonable requests) and didactic information (e.g., the role of dopamine in schizophrenia and substance use), and receive social reinforcement for effort. Rather than teaching generic problem solving skills and coping strategies that can be adapted to a host of diverse situations, we focus on specific skills effective for handling a few key, high risk situations (e.g., what do you do when you are offered coke by your brother or...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Preface
• PART I.
• PART II.
• PART III.
• References
• Index