People struggling with co-occurring mental illness and substance use disorders (SUDs) have unique problems that when addressed simultaneously will likely result in the most desirable outcomes. Historically, mental health services as a whole have not been prepared to deal with people who have both afflictions (Sciacca, 1991). Often only one of the two problems is identified. If in fact both are recognized, the individual may bounce back and forth between fragmented and uncoordinated services leaving much room to fall in between the cracks. When a multiple team approach is used, chances for recovery improve instilling more hope and optimism for those suffering from these concurrent conditions (Sciacca, 1991).
Building Social/Interpersonal Skills
Since some people find themselves more easily accepted by groups whose social activity is based on drug use, an identity based on drug addiction or alcoholism is sometimes seen as more acceptable than one based on mental illness (Aharonovich et. al., 2008). Consequently, peer pressure and a lack of healthy coping mechanisms may contribute to a Mentally Ill Chemical Abuser (MICA) patient’s drug use. For people with co-occurring disorders participating in support groups can serve to reinforce opportunities for healthy socialization, increase access to recreational activities, and develop more positive peer influences. Participation in such groups may also deal with education and awareness of dual diagnosis issues, medication management, communication skills, as well as improvement in activities of daily living.
Understanding Environmental Factors
As a consequence of mental illness many MICA individuals may find themselves living in neighborhoods where drugs are easily accessible increasing the potential to self-medicate. Additionally, after MICA individuals begin to seek psychiatric care continued drug use will interfere with the efficacy of prescribed medications, in turn increasing risk for instability due to a resurgence of co-occurring psychiatric symptoms. It has become common practice for dually diagnosed patients to be referred to community residence rehabilitation programs. Usually residential rehabilitation involves a stay of a few months to a year. In these facilities there is an emphasis on group affiliation and ongoing counseling to prevent relapse. However, housing difficulties at this stage may arise as there is often no tolerance of drug use in the rehabilitation facilities.
In places where there are dual diagnosis treatment centers, MICA individuals receive services that are tailored to the individual and include different types of assistance that go beyond standard therapy or medication, such as outreach, job and housing assistance, family counseling, and money management. These programs view substance abuse as intertwined with mental illness, and therefore provide solutions to both illnesses at the same time.
Relapse Prevention
Relapse of substance abuse may increase risk of experiencing a mental health decompensation by exposing individuals to triggers such as feelings of failure and alienation. Drug/alcohol use can also lead to a loss of support systems, resulting in recurrent relapses and hospital stays (Aharonovich et. al., 2008). The typical relapse prevention treatment program usually meets 3-5 days a week, 4-6 hours/day and may benefit people who require medical monitoring on an outpatient basis.
A case manager and sponsor may be available to the individual to provide routine contact and encourage follow-up with doctor’s appointments, and other forms of treatment. Talk therapy offers an opportunity for emotional healing through exploration and education. Examining deeply rooted thoughts and emotions can help to identify the vulnerability factors for SUDs and can be helpful in making constructive choices promoting healthier coping mechanisms.
Addressing Denial in Group Work
The most significant component in group work is the supportive nature of the group process. When clients are in denial it may be good to emphasize this supportive feature by asking: “Even though you don’t see substance abuse as a problem for yourself, do you think you could be supportive of the other group members who are seeking help for their substance abuse?” In this way the MICA group leader accepts the denial state, while at the same time setting the tone for a supportive group process. Most clients respond affirmatively to the question, and their ability to contribute is inherent in that response. Group members are informed that they will encounter various stages of treatment readiness in other group members: “In our group there are persons like yourself who don’t think they have a substance abuse problem; there are also persons who think they may have a problem and want to abstain, but are not yet able to do so; and there are persons who know they have a problem and who are successfully abstaining.” This information prepares group attendants to accept the varying readiness levels in others and helps to eliminate discussion regarding comparisons with other clients (Sciacca, 1991).
A secondary component in group work is the educational aspect of the process. The MICA leader attempts to establish a reason for the person in denial to participate by asking, “In this group we learn a lot about alcohol and drugs. Do you have any interest in learning about this?” Members who have denied any involvement with substances at this point, may comfortably express interest in receiving education at the very least (Sciacca, 1991). Interest in education is perceived as an acceptable purpose for participation allowing for the group process to take effect without the resistance that may be brought about in some individuals when addressing denial.
Specific education on both mental illness and substance abuse is an essential part of the treatment process. Areas can include: mixing medication with substances; the symptoms and syndromes specific to each disorder; the forms of treatment utilized for each disorder; the physiological disease concepts for each disorder in contrast to moral judgment and stigma; and the process of rehabilitation and recovery for each disorder (Imel et. al., 2008).
Providing appropriate, integrated services for people with dual diagnosis can improve recovery and overall health, and restructure the effects the disorders have on their family, friends and society. By helping these people stay in treatment, finding housing and jobs, developing better social skills, and enhancing insight and judgment, there is the potential to reduce the prevalence of HIV/AIDS, domestic violence and violent crimes.
According to Rethinking Substance Abuse by William R. Miller and Kathleen M. Carroll: 1) Fifty-three percent of drug abusers and 37% of alcohol abusers have at least one serious mental illness; 2) Roughly 50% of individuals with severe mental disorders are affected by substance abuse; 3) Twenty-nine percent of all people diagnosed as mentally ill abuse either alcohol or drugs; and 4) Sixteen percent of jail and prison inmates are estimated to have severe mental and substance abuse disorders.
Group work for dual diagnosis should provide treatment for: Drug and Alcohol Use, Behavioral Addictions, Codependency Patterns, Mental Health and Psychiatric Status, Trauma Issues, Eating Disorders, Sexual Addiction and Compulsivity, Family Functioning, Social Relationships, Physical Health and Fitness, Diet and Nutrition, Vocational and Educational Needs, and Legal Problems.
