No Mind Is an Island: Integrated Substance Abuse Treatment for Schizophrenia – Part 1

By Kim T. Mueser, PhD

Traditional Dual Disorder Treatment Approaches
Integrated Treatment for Dual Disorders
Assessment
Detection
Classification
Functional Assessment
Functional Analysis
Treatment Planning

People diagnosed with schizophrenia are at increased vulnerability for developing alcohol and drug abuse problems (ie, "dual diagnosis") compared to the general population. For example, while the lifetime rate of substance abuse or dependence in the general population is about 16%, nearly 50% of individuals with schizophrenia also have substance use problems.^1,2 Furthermore, substance abuse can worsen secondary outcomes in schizophrenia-it can precipitate relapses and re-hospitalizations; negatively affect the person's social functioning, overall health status, and ability to retain housing; promote and/or facilitate criminal behavior. Because of these and other problems associated with substance abuse in schizophrenia, rapid detection and treatment are of critical importance to the overall management of persons with schizophrenia.

This article discusses clinical guidelines for the recognition and treatment of substance abuse in persons with schizophrenia, based on a comprehensive approach described by Mueser and colleagues.³ First, it establishes the rationale for providing integrated substance abuse and mental health treatments, rather than having those services provided by different clinicians or agencies. It also reviews the assessment of substance abuse problems and effective treatment planning. Readers will also find a summary of the principles of effective treatment, with descriptions and commentary on specific psychotherapeutic approaches.

Traditional Dual Disorder Treatment Approaches

Historically, intervention for substance abuse in schizophrenia relied on either parallel or sequential treatment approaches. In the parallel approach, treatment for schizophrenia and substance abuse are provided by different clinicians, usually working for different agencies. In the sequential approach to treating persons diagnosed with schizophrenia and substance abuse disorders, mental healthcare professionals, whether working from one or several different agencies, treat first one disorder then the second disorder. Because there are numerous problems associated with both of these approaches, they are now considered to be ineffective for most individuals with schizophrenia. The primary problems with the parallel approach are that individuals with mental illness often experience great difficulty in accessing the necessary services to treat both schizophrenia and substance abuse; there has historically been a lack of follow-through on substance abuse treatment; services are often poorly coordinated; and inconsistent messages are often provided by different clinicians (eg, substance abuse and mental health clinicians may place different, sometimes conflicting, emphasis on abstinence vs. harm reduction). The primary difficulty with sequential treatment is that mental illness and substance use disorders tend to exacerbate one another, making it difficult to treat one without simultaneously attending to the other.

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Integrated Treatment for Dual Disorders

In order to overcome the problems associated with parallel and sequential treatment approaches, integrated treatment for the two disorders is now widely recommended. Integrated treatment is defined as the concurrent provision of mental health and substance abuse services by the same clinician or team of clinicians. The clinicians who provide treatment also take responsibility for integrating interventions for the two disorders. This integration follows naturally when a detailed assessment has been conducted that is aimed at understanding the interactions between schizophrenia and substance abuse disorder.

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Assessment

The process of assessment can be divided into five steps: detection, classification, functional assessment, functional analysis, and treatment planning. Ongoing assessment is critical to evaluating the effects of treatment; substance abuse must be reassessed on a routine basis and treatment plans should be modified accordingly. A brief description of each step of assessment is provided below.

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Detection

The goal of detection is to identify individuals with schizophrenia who may also be experiencing problems related to drug or alcohol use. Because of the effects of untreated substance abuse on schizophrenia, it is preferable to be over-inclusive rather than under-inclusive during this step. When trying to identify clients with potential substance use problems, clinicians should be aware that people with schizophrenia have a high sensitivity to the effects of alcohol and drugs, and that even a modest level of substance use may trigger negative consequences and warrant treatment. Therefore, clinicians should carefully explore the effects of any alcohol or drug use in their clients with schizophrenia.

Information about possible substance use problems can be gleaned by tapping multiple sources, including the treating clinician's own observations; information and reports from clients, their significant others, and other clinicians; and other available records. Direct interviews with clients can be effective in identifying substance use, although self-reports often minimize the extent of use. Clinicians should be aware of the common exacerbating effects substance use can have in individuals with schizophrenia, such as frequent relapses, money problems, social difficulties, family conflict, and depression. These complications, especially in clients who have previously shown better functioning, may signal the presence of substance use problems.

Standardized screening instruments for substance abuse can also be useful in people with schizophrenia. Instruments that show good accuracy and sensitivity in this population include the Alcohol Use Identification Test,⁴ the Drug Abuse Screening Test,⁵ and the Dartmouth Assessment of Lifestyle Instrument.^3,6 When a clinician knows that a client uses substances but the clinician is unsure as to the extent of the their effects, it is safest to assume that the client has a substance use problem and to proceed on to the classification step.

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Classification

The DSM-IV⁷ classifies substance use disorders into two categories: abuse and dependence. Abuse is defined by a pattern of substance use resulting in problems in social relationships, poor health, criminality, or use in unsafe situations. Dependence is defined by either psychological dependence (ie, giving up important activities in order to obtain and use substances, repeated unsuccessful efforts to cut down or stop, and/or using more substance than intended) or physical dependence (ie, increased tolerance to the effects of substances and withdrawal symptoms when substance is not used). People with schizophrenia tend to be highly susceptible to psychological dependence, but because they often abuse moderate amounts of substances they less often develop physical dependence.

Classification involves gaining a detailed understanding of the consequences of the client's substance use. Such information is best obtained from clients, their significant others, and clinical observations. Two useful instruments for classifying substance use problems and monitoring substance abuse over time are the Alcohol Use Scale-Revised (AUS) and Drug Use Scale-Revised (DUS).³ These instruments focus on the client's worst month of substance use over the past six months, and prompt clinicians to consider the specific criteria for abuse and dependence. Each scale yields a five-point rating pertaining to the client's substance use over the last six months: 1 = no substance use, 2 = substance use without impairment, 3 = abuse, 4 = dependence, 5= severe dependence with institutionalization (ie, prolonged or multiple hospitalizations or incarcerations related to substance use). Clients with substance abuse or dependence in the past six months need integrated dual disorder treatment. Assessments based on the scales should be repeated every six months.

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Functional Assessment

Once a substance use disorder has been confirmed, the clinician should gather more detailed information about the nature of the use, the client's level of functioning, and possible reasons for using substances. This information is usually collected gradually, in the context of developing a therapeutic relationship, if one does not already exist. The goal of this step is to gain an understanding of the client's functioning across different life domains, such as relationships, family support or conflict, self-care, involvement in work or school activities, leisure activities, and symptoms. Details about the client's pattern of using substances should also be obtained, including the types of substances used, the situations in which they are used, frequency and intensity of use, and the perceived positive and negative effects of using.

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Functional Analysis

The purpose of the functional analysis (also called a contextual analysis) is to develop an understanding of how substance use insinuates itself into the client's life, and to identify factors that maintain ongoing substance use and present a barrier to sobriety. Rather than assuming that substance use is an irrational behavior that clients are compelled to engage in despite its negative consequences, a functional analysis assumes substance use is maintained by the positive effects of using substances and the negative effects of not using. Of course, the positive effects can be quite short-lived compared to the negative long-term effects. However, because of the cognitive impairments common in people with schizophrenia,⁸ clients often have difficulty with long-term planning and instead make decisions based on anticipated short-term gains.

Substance use is usually associated with at least one of four common motives: reduction of distress (eg, coping with hallucinations, depression, or anxiety), leisure and recreation (eg, because it "feels good," to get "high"), social facilitation (eg, something to do with friends, a way to meet people, peer pressure), and structure and a sense of purpose (eg, something to look forward to). Understanding which reasons for using substances are most important to the client can inform treatment planning. Clients will be more successful in achieving sobriety if they are helped to develop alternative ways of getting their needs met.

One useful strategy to aid in conducting the functional analysis is to complete a payoff matrix. (Figure 1) A payoff matrix is a two-by-two table that provides space for clients to list the advantages and disadvantages of sobriety and substance use. The payoff matrix is completed by the clinician using all the available information, and is designed to provide insight into why the client continues to use substances, despite their negative consequences. Once the advantages and disadvantages of using substances and sobriety have been identified, treatment can focus on modifying some of those consequences. There are four general approaches to reducing substance use behavior, based on the quadrants of the payoff matrix:

• Decrease the advantages of using substances
• Increase the disadvantages of using substances
• Increase the advantages of sobriety
• Decrease the disadvantages of sobriety

In practice, it is difficult to decrease the naturally reinforcing effects of using substances. Many clients already pay a high price for using substances, so it is also difficult to increase the disadvantages of using. Rather, the most effective treatment usually involves helping clients become more aware of the advantages of leading a sober lifestyle (ie, increasing the advantages of sobriety), and using rehabilitation to equip clients with the skills and opportunities for getting their needs met in ways other than using substances (ie, reducing the disadvantages of sobriety).

• the most effective treatment usually involves helping clients become

For example, possible advantages of sobriety that may engage and motivate clients include regaining control over their money, returning to school, getting a job, or becoming a better role model for their children. By helping clients pursue such goals, and exploring with them how using substances may interfere with attaining those goals, the perceived advantages of sobriety may be increased. Similarly, clients may use substances in order to socialize with others or cope with distressing symptoms, as a form of recreation, or because it gives them something to look forward to. Helping clients learn alternative strategies for coping with symptoms, socializing with others, and setting and achieving goals can decrease the disadvantages of developing a sober lifestyle.

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Treatment Planning

Treatment planning flows naturally from the functional analysis, and should address strategies for motivating clients to develop a sober lifestyle as well as rehabilitation aimed at helping clients develop skills for finding ways to meet their needs without resorting to substance use. Education and motivational interviewing are the primary strategies used to increase the client's desire to become sober. Cognitive-behavioral strategies and other rehabilitation approaches are the primary strategies for helping people develop alternative ways of meeting their needs in the absence of substance use. Treatment plans should be re-evaluated at least every six months, and more often if necessary.

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Kim T. Mueser is a professor in the Departments of Psychiatry and Community and Family Medicine at Dartmouth Medical School, and a researcher at the New Hampshire-Dartmouth Psychiatric Research Center. He may be reached via email at Kim.T.Mueser@Dartmouth.edu.

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