7 STEPS TO DEVELOPING A COMPREHENSIVE DUAL DISORDERS PROGRAM IN A MENTAL HEALTH SETTING By Mark Sanders, LCSW, CADC Studies indicate that 50% of the chronically mentally ill have concurrent substance abuse problems. Below are seven steps for developing a comprehensive dual disorders program in a mental health facility. Step 1: Provide substance abuse and mental health training for all staff. This is a necessary step before developing the program. Not only is it important for workers to be trained in core areas such as pharmacology, assessment skills, individual group and familial approaches to working with the dually diagnosed, etc., employees should be able to answer five attitudinal questions, which are necessary prerequisites for working with dually diagnosed clients. These include: What are my feelings about shifting from a focus on treating mental illness to a focus on treating dual disorders? Most people don t like change! Therefore, as a part of training, people need to have the opportunity to voice fears,
apprehension, and frustration about this new approach. Without this opportunity many staff might resist delivering dual diagnosis services, even if they have been outlined on paper. In my work as a dual disorders consultant, I have discovered that, as the staff s knowledge increases via training on how to effectively work with dual disordered clients, their attitudes often change as well. What is my attitude about alcohol and drugs? Many people who work in the mental health field do not readily embrace the medical model or disease concept of addiction. Quite a few have moralistic views of drug use. Training could be instrumental in helping participants understand the impact of the moralistic view of addiction on the therapeutic relationship. How has alcohol and drugs effected my life personally? Most Americans are personally touched by alcoholism and drug abuse through an uncle s addiction, aunt, parent, or close friend. Only a small percentage of people get a chance to examine the impact. This is a necessary step in order to work with dual disordered clients. Unresolved feelings of anger, frustration, and resentment can greatly impact the therapeutic relationship. What is my personal relationship with alcohol and other drugs? Although personal, this issue is worth examining, even if you examine it alone. I have met many mental health professionals who struggle to approach the issue of drinking and drug use with dual disordered clients because they have not examined their 2
own drug use. Some feel guilty about talking to their clients about drug use, knowing that they re planning to have a drink tonight with co-workers. Only by examining this issue can the counselor get a degree of comfort in this area. One counselor resolved this issue by saying, I m a social drinker, and as an adult, I have the right to drink socially. At the same time, most of my clients have a dual disorder. I have a responsibility to help them recover from their dual disorder. What is my attitude about 12-step and other self-help groups? Many helping professionals express a dislike of 12-step groups. Surprisingly, when asked if they ve ever attended a 12-step meeting, workers in the mental health field with whom I have talked, often say no. My recommendation is that as a part of training, mental health professionals be encouraged to attend one or two open 12-step group meetings. It is okay to dislike the 12-step approach to recovery. At least by attending the meeting you are aware of what you dislike. Training should also stress the three important qualities of an effective dual disorders counselor. These qualities include: Patience. I heard Ken Minkoff, M.D., state in a workshop in Chicago that it can take dual disordered clients up to eleven years or longer to come to terms with having a dual diagnosis. What they need in the meantime is good quality care from helping professionals. It might be refreshing for 3
counselors who are beginning to work with dual disordered clients to know that just as farmers may not see the fruits of their labor in the season in which they planted the seeds, the counselor may not see instant recovery, but that their work does matter! The ability to look for small signs of progress. Those who define success with dual disordered clients as cure, are great candidates for professional burnout. It is important for workers to look for small signs of progress with this population. Success can include helping the client decrease the number of hospitalizations per year, helping clients improve their relationships with family members, helping clients attend self-help groups, etc. Creativity. Relapse rates remain quite high among dually disordered clients. Training should also focus on encouraging staff to think creatively when it comes to developing programs for dual disordered clients. From my experience, feelings of hopelessness set in when we run out of ideas, questions, and creative strategies to try to help clients recover. 4
Step 2. Provide training for all medicating physicians. There are three important areas upon which this training should focus: The doctors should receive education about how to deal with client drugseeking behavior. Many dual disordered clients attempt to manipulate their doctors into giving them addictive medicine, while the rest of the treatment team tries to help the client recover. Cross tolerance and cross addiction. The role of doctors as multidisciplinary team members in a comprehensive dual disorders program. Step 3. Develop flexible policies. Your policy should state the goals of your program, your approach to working with dual disordered clients, criteria for admission and discharge, how to deal with relapse, etc. Since our knowledge of how to work with dual disordered clients seems to increase daily, our policies need to be flexible. We should be willing to change policies as our knowledge increases. Step 4. Do a thorough dual disorders assessment on all clients who enter your program. The prevalence of dual disorders among the mentally ill is too high not to. Assessors should be taught that, because of protracted withdrawal and the fact that alcohol and other drugs can produce symptoms that mimic most forms of mental 5
illness, it can take two to four weeks to make accurate diagnoses. It is recommended that you have a two-track system for clients following your assessment. Those clients whose drug use and drinking patterns are no use, social use, or abuse, should receive time-limited alcohol and drug education while in your program. Such an educational group should focus on: The impact of the use of alcohol and other drugs on the therapeutic effectiveness of psychotropic medication. How alcohol and illicit drugs can exacerbate psychiatric symptoms. The risk of overdose caused by drinking alcohol while taking psychotropic medication. Those clients diagnosed as alcohol/drug dependent should receive services in a dual disorder treatment track. Step 5: Provide comprehensive treatment for both disorders. Historically, the rift between the chemical dependence and mental health fields has forced dual disordered clients to receive the see-saw approach to treatment (i.e., mental health treatment in a mental health facility and treatment for their addiction in a chemical dependence facility). This fragmentation is not the most effective approach. Today, there are many mental health facilities that claim to offer dual disorders services, but that are actually offering alcohol and drug education/counseling in a mental 6
health setting. It is important for workers to talk often about mental illness, chemical dependence, and the interaction between the two. Workers should use the term dual disorders in all educational lectures, groups, family sessions, etc. An important part of comprehensive dual disorders treatment is group therapy. An effective program has a variety of groups, including and not limited to: Psychoeducation groups. Didactic in nature, these groups cover topics such as the signs and symptoms of mental illness, signs and symptoms of chemical dependence, what is a dual disorder? and how medication works in the brain. Each didactic presentation should be followed by discussion. As a consultant in the dual disorders arena, I have found that psychiatrists are often excellent facilitators of psychoeducation groups because of their vast knowledge. Utilization of a doctor in this particular role also constitutes a form of creative programming. Dual disorders psychotherapy groups. Dual disorders relapse prevention groups. Transition groups. The goal is to help members transition from your program into the community. 7
Dual disorders self-help groups, perhaps led by a person who is recovering from a dual disorder. Occupational and art therapy groups for dual disordered clients. Groups that develop living skills. Examples of such groups include: stress management groups; current event groups; job readiness and employment groups; health and nutrition groups. Finally, an important component of comprehensive dual disorders treatment is multidisciplinary team work. It is important for the multidisciplinary team to meet regularly to discuss strategies for working with specific dual disordered clients. Step 6. Work With the Entire Family. The chemical dependence and mental health literature talks about the importance of family involvement in clients recovery efforts. In many programs, only a few family members actually participate in the family component. Below is a list of five strategies for increasing family involvement in your dual disorders program: In order to successfully have a strong family component, your organization needs to view family involvement as a top priority. 8
Consider requiring a family member to attend the initial intake interview. This could be instrumental in establishing a bond between the program and the family. The worker should be responsible for contacting family members. Some may view this as a form of enabling, but so often family members are tired and angry at their dual disordered relative; thus, the worker may have more leverage to get them to attend. Utilize your best and most experienced workers to recruit and work with families. Many programs treat family involvement as an afterthought. This is often demonstrated by assigning their least experienced workers or brand-new students to work with families. Do not assume that workers know how to recruit and counsel families. Training is most important in these areas. It is my recommendation that a comprehensive dual disorders family program have psychoeducation groups for the family, a multiple family support group, and also provide family therapy for each family separately. 9
Step 7. The staff takes good care of themselves. It is no secret that the dual disordered population is challenging to work with. Clients with a dual disorder are often twice as sick as someone who has a single diagnosis of mental illness or chemical dependence. The following seven steps are recommended to insure that your team is able to maintain a high degree of health while working with dual disordered clients: Continue to support each other during stressful times and for good work. Continue to increase your knowledge about how to effectively work with dually disordered clients. Consider co-leadership in most of your dual disordered groups. This adds a built in mechanism of support as dual disordered groups can be very challenging. If your staff is small in number, consider utilizing undergraduate and graduate students as co-leaders. Take your break each day and lunch. Remember to laugh. 10
Discuss feelings regularly as a team about the challenges of working with dual disordered clients, as keeping feelings inside can lead to frustration with the work. Remember that good clinical supervision is important. Remind yourself often, as an individual and as a team, that you are powerless over determining when someone actually recovers from a dual disorder, but you are responsible to simply do the best job you can. 11
ABOUT THE AUTHOR Mark Sanders, LCSW, CADC, is a member of the faculty of the Addictions Studies Program at Governors State University. He is an international speaker in the addictions field whose presentations have reached thousands throughout the United States, Europe, Canada, and the Caribbean Islands. He is co-author of Recovery Management and Relationship Detox: How To Have Healthy Relationships in Recovery. Mark can be reached at onthemark25@aol.com 12