Promising Treatments for Dual Diagnosis
Brian E. Bride, Ph.D.; Bethany G. Womack, B.A.; Samuel A. MacMaster, Ph.D.
In recent years, research supported by the National Institutes of Drug Abuse (NIDA, 1999) has identified a variety of treatment approaches that have been found to be effective in the treatment of drug addiction. A number of those approaches are adaptable to the treatment of individuals with co-occurring disorders in a variety of settings. The purpose of this article is to provide a brief introduction to four of the treatment approaches identified by NIDA as efficacious: relapse prevention, motivational enhancement therapy, contingency management, and the community reinforcement approach. According to NIDA (1999), these approaches should be used to supplement or enhance, not to replace, existing treatment programs. Some, but not all, of the approaches have demonstrated their effectiveness with individuals with co-occurring disorders.
Contingency Management Contingency management is a behaviorally based, psycho-social intervention that uses various rewards, or contingencies, to reinforce abstinence. Typically, a participant will be given a small amount of cash or a voucher for some item or service when a certain number of clean urine samples are achieved. Often, scheduled reinforcement is used so that the value of the contingency increases with the number of consecutive clean samples (Kaminer, 2000; Higgins & Petry, 1999). Advantages of contingency management include its compatibility with pharmacotherapy and other forms of treatment. By immediately using positive reinforcement for abstaining, contingency management has been shown to be useful with clients who have difficulty focusing on the long-term rewards of reducing substance use (Higgins, Badger, & Budney, 2000; Kaminer, 2000).
Contingency management is also effective in encouraging behaviors that are not related to drug use, and has been demonstrated to be effective for a wide variety of populations. It has been effectively used to increase the number of positive behaviors such as attending support group meetings or completing tasks related to seeking employment (Petry, Tedford, & Martin, 2001). Further, contingency management has been shown to be effective in reducing use among individuals with co-occurring disorders and in those whose prognosis of reducing substance use is poor due to persistent multiple drug use (Chutuape, Silverman, & Stitzer, 1998; Higgins et al., 2000; Sigmon, Steingard, Badger, Anthony, & Higgins, 2000).
Motivational Enhancement Therapy Motivational enhancement therapy is a cognitive-behavioral approach that focuses on resolving a client’s ambivalence surrounding their substance use and the major changes that are involved in moving from using behaviors to abstinence. It is theoretically based in the transtheoretical model, which posits that actual change occurs through an internal process whereby a person begins to see the benefits of changing behavior as outweighing the benefits of maintaining behavior. Through this process, the
individual comes to believe that they are capable of changing problematic behavior (Prochaska, DiClemente, & Norcross, 1992). The professional’s role is to assist the client in making his or her own changes by facilitating the individual’s movement through the stages of change.
A key component of motivational enhancement therapy is the therapeutic alliance. The professional acts not as an advocate for abstinence, but rather as an advocate for the client’s ability to make decisions regarding their own change, even while acknowledging those feelings of ambivalence. Positive outcomes are associated with professionals who employ a highly empathetic style to encourage feelings of self-efficacy surrounding the client’s ability to successfully change problematic using behavior (Miller, 1996; Shaffer & Simoneau, 2001). Motivational enhancement techniques can be applied as an individual treatment or used as components of other treatment modalities, and has demonstrated positive outcomes in inpatient group settings for individuals with dual diagnosis (Van Horn & Bux, 2001). Further, the focus on exploring one’s feelings of ambivalence and utilizing internal resources to make self-determined changes appears be particularly useful as an engaging and complimentary element of traditional mental health treatment with individuals with co-occurring diagnoses of schizophrenia (Ziedonis & Nickou, 2001; Ziedonis & Stern, 2001).
Relapse Prevention Therapy Another cognitive-behavioral strategy, Relapse Prevention Therapy (RPT), focuses on preventing an initial relapse of substance use or on helping clients who are experiencing a relapse to return to abstinence (Marlatt, 1982; Marlatt & Gordon, 1985; Marlatt & George, 1984; Marlatt, 1990; Marlatt & Barrett, 1994; Marlatt, 1996, Marlatt & Parks, 2000). According to the model, lapses or single incidents of slipping into the avoided behaviors are considered important and expected components of the behavior change process. Through trial-and-error, new response patterns in high-risk situations are gradually acquired, corrected, and strengthened (Marlatt & Gordon, 1985).
Drawing on social learning theory, RPT focuses on coping during “high-risk situations” (situations that pose a threat to the individual’s sense of control and increase the risk of relapse), managing “euphoric recall” (the experience of re-feeling the positive emotions associated with the drug using experience), and increasing the availability of socially learned coping skills. RPT provides coping skills training and behavioral techniques that help clients to: understand relapse as a process; identify and cope effectively with high-risk situations; cope with cravings; minimize the effects of a lapse; stay engaged with treatment after a relapse; and make long lasting life-style changes (Parks & Marlatt, 1999). The goal of this treatment approach is for the individual to become aware of their own high-risk situations and to learn effective coping skills and cognitive strategies to deal with situations in which they would have previously used substances, resulting in greater self-efficacy and confidence (Marlatt & Gordon, 1985).
Extensive research exists to suggest that RPT is effective at reducing relapse. While long-term abstinence rates remain about the same with relapse prevention as with other methods, at one-year follow-up fewer lapses were seen with relapse prevention (Carroll, 1996). Several meta-analyses of the results of this technique
have shown it to be effective in helping to maintain the changes brought on by substance abuse treatment, both in reducing the frequency of relapse and the intensity of each individual lapse (Carrol, 1996; Dimeff & Marlatt, 1998; Irvin et al., 1999; Rawson et al, 1993).
Community Reinforcement Approach Like the previous two treatment approaches, the Community Reinforcement Approach (CRA) is based in cognitive-behavior theory. Its aim is to make abstinence more rewarding than using. It is based on the belief that environmental contingencies can play a powerful role in supporting or discouraging substance abuse and that these environmental factors need to be addressed (Smith, Meyers, & Miller, 2001). In order to increase the value of an abstinent life-style to an active user these factors need to be addressed (Smith et al., 2001).
CRA focuses on four major environmental areas of functioning: the familial, social, recreational, and occupational. Assessment is needed in all four areas to address what benefits the person is receiving from these areas by continuing their using behavior. Once these benefits are identified, changes can be made to modify the environment to one that is more rewarding for abstinence (Budney & Higgins, 1998; Smith et al., 2001). Such changes may include vocational skills training, communication skills building in stressful relationships, and substituting recreational activities that facilitate drug or alcohol abuse with other activities. Increasing the client’s satisfaction in these four areas is critical to making CRA effective in long-term behavior change (Budney & Higgins, 1998).
CRA can also be used with concerned friends and families seeking to assist a resistant loved one in engaging in treatment (Smith et al., 2001). This approach stresses the environmental changes needed to help make behavior change possible and supplies concerned loved ones with a non-confrontational means of introducing a person to treatment. Research shows a consistently higher rate of treatment entry among resistant users after their friends and family were given CRA counseling when compared to groups attempting to engage without CRA (Smith et al., 2001; Meyers et al., 1999).
Conclusion Important strides are being made in research supporting new and innovative approaches to substance abuse treatment. It is important to keep abreast of these improvements, as many will apply directly to services being provided to individuals with co-occurring disorders. The approaches discussed in this article are easily adaptable and can be incorporated to supplement or enhance existing treatment programs. Further, these approaches can be used in combination to address different aspects of clients’s treatment needs. While this article discusses effective treatment approaches in the context of addressing substance abuse, they can also be adapted to address other problematic behaviors, such as noncompliance with medication regimens. Some of the above approaches have already demonstrated effectiveness with dually diagnosed populations, however further research is needed to determine what conditions will optimize their effectiveness.
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