No Mind Is an Island: Integrated Substance Abuse Treatment for Schizophrenia – Part 2

By Kim T. Mueser, PhD

Treatment
Stage-wise Treatment
Comprehensive Treatment
Long-term Commitment
Harm Reduction
Multiple Psychotherapeutic Options
Treatment Strategies
Motivational Enhancement
Educational Strategies
Cognitive-Behavioral Strategies
Conclusions

Treatment

Integrated treatment is guided by several overarching principles. These principles are briefly reviewed here, followed by a description of therapeutic treatment strategies.

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Stage-wise Treatment

It is widely accepted that people go through a series of discrete motivational stages when they are in the process of changing health behaviors such as substance abuse or smoking, or trying to lose weight. Five different stages of change have been described:

Pre-contemplation: The person is not thinking about change

Contemplation: The person is thinking about change

Preparation: The person is preparing to change

Action: The person is changing behavior

Maintenance: The person is trying to maintain the behavior change

These stages of change have been adapted to describe specific stages of treatment that individuals with a dual disorder go through in the process of treatment for their substance abuse. The stages-of-treatment concept assumes that changes in substance abuse behavior occur in the context of a therapeutic relationship, and that motivation to change behavior precedes efforts to reduce substance use. At the engagement stage, the client does not yet have a therapeutic relationship, and therefore the goal is to establish such a relationship before making efforts to persuade the client to work on his or her substance use problems. Outreach to connect with clients in the community, helping clients resolve a crisis or pressing problem, or providing practical assistance are ways of establishing this relationship. In the persuasion stage, clients are seeing a clinician on a regular basis and have a working relationship, but the client is not motivated to develop a sober lifestyle. Therefore, the goal of this stage is to help the client develop motivation before trying to reduce substance use and achieve sobriety. Motivational interviewing can be used to increase the perceived advantages of sobriety, and psychiatric rehabilitation can be used to help the person develop new skills for getting his or her needs met in ways in less destructive ways, thereby instilling motivation for sobriety.

Once motivation for sobriety is established, as indicated by reduced substance use or efforts to reduce use, the active treatment stage focuses on helping the client become sober. Strategies such as developing a relapse prevention plan, practicing skills for dealing with high-risk situations (eg, being offered substances by friends), or participation in a self-help group can be helpful. Finally, when sobriety has been achieved, the relapse prevention stage focuses on maintaining the client's awareness that a relapse into substance abuse could occur, and extending the recovery into other areas of functioning such as work and social relationships.

Interventions are most effective when they are matched to the client's stage of treatment. For example, at the beginning of treatment, when the clinician does not yet have a therapeutic relationship with the client, efforts should focus on developing this relationship in an empathic, nonjudgmental manner, consistent with the engagement stage of treatment, rather than confronting the individual about the consequences of using substances. Similarly, when a therapeutic relationship has been established, but there is no evidence that the client is motivated to develop a sober lifestyle, treatment should focus on instilling motivation for sobriety, consistent with the persuasion stage of treatment, rather than developing relapse prevention plans (eg, dealing with high-risk situations) or prompting the client to attend self-help groups for addiction.

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Comprehensive Treatment

In order for dual disorder services to be effective, they must also be comprehensive, and able to meet the broad range of client needs. These needs include access to psychiatric rehabilitation to address deficient social skills, vocational rehabilitation, family psychoeducation, and training in illness self-management; housing services; healthcare; psychopharmacological treatment; and case management, including assertive case management if needed. Individuals with schizophrenia, including those with dual disorders, need a wide range of services, and such services should not narrowly focus on substance use problems.

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Long-term Commitment

People with dual disorders require long-term treatment. Similar to schizophrenia, substance use disorders in some individuals can be chronic, relapsing disorders. Research indicates that over the long term most persons with dual disorders experience sustained remissions from their substance use problems.¹ Thus, artificial time constraints on the treatment of these disorders should not be imposed.

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Harm Reduction

Abstinence is the long-term goal for individuals with schizophrenia and substance use disorders. However, many clients are not initially committed to abstinence. With these individuals, a program of gradual reduction of substance use may be a helpful step toward achieving this long-term goal. In addition, attention should be given to minimizing the harmful consequences of substance use whenever possible, such as reducing exposure to infectious disease by teaching safe sex practices to clients who have a history of trading sex for alcohol or drugs.²

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Multiple Psychotherapeutic Options

Treatment for dual disorders is most effective when clinicians have a variety of different therapeutic modalities at their disposal. Individual, group, and family approaches can all be helpful. Some clients are easier to engage individually than in groups, whereas the opposite is true for others. Treatment for some people is most effective when it is integrated into an overall program for teaching the family how to manage schizophrenia and associated substance use problems. Clients may benefit from a combination of individual, group, and family approaches. Having the flexibility to provide integrated treatment in a variety of approaches maximizes the chances of matching the therapeutic modality to the client's needs and circumstances.

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Treatment Strategies

Psychotherapeutic treatment strategies for dual disorders can be broadly grouped into motivational, educational, and cognitive-behavioral techniques. Each of these techniques can be implemented in individual, group, or family treatment modalities. The most effective treatment is usually achieved when a combination of these strategies is used.

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Motivational Enhancement

Motivation to change substance use habits is critical to effective treatment for dual disorders. Ambivalence about becoming sober is a natural part of recovery from substance abuse, since people often have some awareness of the negative effects of using substances, but are also dependent on using substances, either physically or to get their psychological needs met. One useful strategy (called the decisional balance) is to help clients make a list of all the advantages and disadvantages of using substances, carefully evaluate the importance of each one, and then explore with the client whether he or she wants to continue using.

Another widely used set of strategies for enhancing motivation is motivational interviewing. The core tenet of motivation interviewing is that people are most motivated to change their behavior when they perceive that such change is in their own best interest, and will help them achieve personally valued goals. Thus, pointing out the negative consequences of using substances is less likely to motivate clients to stop using substances than exploring what the individual's personal values and goals are, and collaboratively examining with the client whether using substances helps or interferes with achieving those goals.

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Motivational interviewing can be broken down into five steps:

Express Empathy

The goal of this step is to understand the client's experience of the world, including the role played in his or her life by substance use. This can be accomplished by assuming a nonjudgmental stance, using reflective listening to demonstrate understanding, and avoiding giving advice.

Develop Personal Goals

When rapport has been established between the clinician and client, attention shifts toward helping the client identify personal goals to work toward in treatment. Many clients have no goals and some are wary of even talking about goals. The clinician should understand this is a normal reaction to the numerous upsets and defeats clients have experienced in their lives, both before and following the onset of schizophrenia.
By developing a trusting relationship, and exploring past and current desires, and even fantasies, the therapist can help clients begin to consider their potential for change. With support and encouragement, clients can identify personal goals that motivate them. Rather than discouraging clients from pursuing ambitious goals, clinicians should instead work with them to break down these goals into smaller steps. Examples of client goals include returning to school, getting a job, living independently, controlling one's own money, being a better parent, making friends, developing a romantic relationship, and identifying enjoyable leisure activities.

Develop Discrepancy

When the steps necessary to achieving desired goals have been identified, the clinician and client work on implementing those steps. This process provides many natural opportunities for the clinician to explore with the client whether his or her use of substances may interfere with making progress toward the desired goal. There are several ways to go about helping clients become aware of the discrepancy between using substances and achieving a goal. Central to all of these strategies is avoiding directly confronting clients about the inconsistencies between using substances and their ability to their desired goals. Instead, the clinician should employ Socratic questioning by asking questions that require the client to consider the possible interference posed by substance use. The clinician can ask the client to consider possible obstacles to achieving a goal, including use of substances. Alternatively, the clinician can frame the question in the opposite way, and ask the client whether using substances may be helpful in attaining the goal, which often leads to the client saying "no," followed by a discussion of why.

Some clients do not think that using substances will interfere with achieving their goals. In these circumstances, the clinician should work with the client to identify steps toward the goal, looking for opportunities to develop discrepancy by asking similar questions when such interference occurs. Asking questions is more effective at developing discrepancy than providing answers because it allows clients to reach their own conclusions, which is more likely to lead to motivation to change their substance use in order to accomplish their goals.

Rolling With Resistance

Even after clients are motivated to change their substance use habits, they may resist that change. Such resistance is normal and is usually due to concerns about what will happen if change occurs. Common concerns involve how the client will handle situations in which they have previously used substances, such as social situations, dealing with symptoms, or recreation. Talking about these concerns with the client, and coming up with practical solutions for addressing them (eg, coping strategies for dealing with symptoms, teaching refusal skills for dealing with offers to use substances) can usually assuage these concerns.

Supporting Self-Efficacy

People can only be successful in changing their behavior if they believe they are capable of change. Therefore, supporting self-efficacy is an important part of motivational interviewing, both when assisting clients in establishing personal goals, and then when helping them achieve sobriety. Self-efficacy can be supported by pointing out clients' accomplishments, helping them become aware of their personal strengths, and reframing past challenges as valuable learning experiences or examples of the client's "survival skills."

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Educational Strategies

Clients benefit from learning about schizophrenia, the principles of its treatment, and the interactions between symptoms and substance use. Information and educational handouts should be presented in small chunks to facilitate comprehension. Material should be reviewed frequently-ask clients questions that require them to process the information you have provided, and help relate this information to clients' own experiences. Many clients find it especially helpful to learn that schizophrenia is a biological illness based on chemical imbalances in the brain. These chemical imbalances can make individuals more sensitive to the effects of drugs and alcohol, which makes it all the more important that clients minimize substance use in order to better manage their illness. Educational handouts on the topics of schizophrenia, the stress-vulnerability model, medications, and substance abuse can be found in Mueser et al (2003).³

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Cognitive-Behavioral Strategies

These strategies involve systematically teaching clients new skills for managing their urges to use substances, dealing with persistent psychiatric symptoms, and developing better interpersonal skills in order to have rewarding relationships. Several specific cognitive-behavioral strategies are especially useful in the treatment of dual disorders.

Relapse Prevention Training

Clients benefit from developing personal relapse prevention plans both for their substance abuse (for clients who are abstinent) and their schizophrenia. Relapse prevention plans are most effective when a significant other, such as a family member, is involved in developing and implementing the plan. The principles of relapse prevention planning are similar for substance abuse and schizophrenia, although separate plans need to be devised because the triggers, warning signs, and action steps differ between the two disorders.

Relapse prevention should involve first identifying situations which have triggered relapses of substance abuse in the past (eg, social situations, having money from a paycheck or disability check in one's pocket). Second, specific warning signs of an impending relapse should be identified (eg, anxiety, depression, cravings, taking a first drink or use of substance). Third, specific strategies should be taught that will enable the client to avoid situations that have triggered relapses in the past (eg, social situations where friends offer substances, getting paid in cash), deal with those situations (eg, skills training to refuse offers to use substances), and cope with warning signs of a relapse (eg, managing cravings, anxiety, or depression, calling someone for support or help). Clients should be encouraged to identify someone they can call for help even if the client begins to use substances again, since a slip can be prevented from developing into a full relapse if rapid action is taken. Fourth, the relapse prevention plan should be written down and rehearsed with anyone who will be involved in implementing it. Fifth, the plan should be posted somewhere prominent for the client to see and copies should be given to every person who have a role in its implementation. Forms for relapse prevention planning are provided in Mueser et al (2003).³

Social Skills Training

Social skills training involves the systematic teaching of more effective interpersonal skills based on the principles of social learning (ie, modeling, role playing, positive and corrective feedback, homework to practice new skills). Social skills training has two broad applications in treating dual disorders. First, as substances are frequently used in social situations, clients can be taught skills for dealing with offers or pressure to use substances. Second, skills training is useful for improving clients' social competence for making friends and getting closer to people so that clients are less dependent upon relationships with substance users.

Coping Skills Training

Clients with schizophrenia often experience difficulties related to persistent symptoms such as hallucinations, depression, anxiety, and sleep disturbances. For some individuals, substance use is an attempt to cope with these distressing symptoms. Helping people learn new coping strategies can provide them with alternatives to using substances as a way of dealing with these experiences.

Coping efficacy is primarily determined by the number of coping strategies that an individual reports being able to use to deal with a particular symptom. Coping skills training involves first teaching the client how to monitor the severity and distress associated with a problematic symptom in order to identify in which situations the symptom is worse and which is less severe. Second, the client's current coping strategies should be evaluated, and any strategies which are found to be effective but underutilized should be increased through in-session practice and home assignments. Third, additional strategies should be identified and taught, one at a time, by the clinician, who should demonstrate the coping strategy in the session, followed by the client practicing it in session, and then making a plan to practice it on his or her own. Follow-up sessions should focus on helping the person develop additional strategies as needed, refining plans for implementing those strategies into his or her life, and evaluating their effectiveness. Mueser and Gingrich describe a wide range of different strategies for coping with symptoms in schizophrenia, including psychotic symptoms, negative symptoms, anxiety, depression, anger, and cognitive difficulties.⁴

Cognitive Therapy

Cognitive therapy involves helping clients identify, challenge, and change thoughts or beliefs about themselves, other people, and the effects of substances that are inaccurate and contribute to distress or problems functioning. Cognitive therapy usually focuses on two topics: negative feelings (eg, depression) and low self-esteem, and the effects of using substances.5 People with dual disorders often have low self-esteem, leading them to think they are worthless, have no future, and are unable to achieve their desires. Clinicians can help clients articulate the thoughts and beliefs that lead to dysphoria, evaluate the evidence for and against these beliefs, and develop more accurate and more balanced perspectives on themselves and their abilities. Clinicians can also help clients challenge their beliefs that using substances is a worthwhile strategy for coping with symptoms, facilitating social contacts, or feeling good. Clients with dual disorders frequently overestimate the benefits of using substances, and de-emphasize the associated costs. By using Socratic questioning to explore clients' beliefs about the benefits of using substances, and evaluating the evidence for and against these beliefs, clinicians can help clients develop more accurate appraisals of the effects of using substances and the advantages of sobriety.

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Conclusions

Integrated treatment is a comprehensive approach to treating schizophrenia and co-occurring substance abuse. Through systematic assessment aimed at understanding the role of using substances in the client's life, effective treatment plans can be developed that take into account the person's motivation to change, and provide rehabilitation to address needs related to socialization, coping, recreation, and involvement in meaningful activities. Through collaboration with the client, significant others, and other treatment team members, clinicians can help clients with dual disorders attain a sober lifestyle, and reap the benefits, including an improved course of illness, better functioning, and feelings of personal well-being and worth.

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