General Treatment Themes for Dually Diagnosed Patients

Because of the limitations of the empirical literature described earlier regarding psychosocial treatments, it may be helpful to draw on general recommendations provided by various writers on this subject (Bellack & DiClemente, 1999; Carey, 1995; Drake et al., 2001; Drake & Mueser, 2000; Najavits et al., 1996; Rounsaville & Carroll, 1997; Ziedonis, Williams, Corrigan, & Smelsen, 2000). Although treatment modalities differ, some common themes can help guide clinicians who must decide how to intervene with their patients. The suggestions are as follows:

• Be empathic and provide support for the difficulty of living with two disorders, but also provide limit setting.

• Assist patients in setting a goal to stop drug or alcohol use. Explore patients' perceptions of the relationship between their substance use and their psychiatric disorders. As part of this process, also explore the longer term relationship between the two (e.g., an individual may report drinking to reduce social anxiety and feel initially better, but then may feel worse the following day) and discuss the advantages of a drug-free life.

• Educate patients and their family members about the symptoms of both disorders and the causal connections between them.

• Monitor symptoms of both disorders (including the use of biological measures such as urine screens for substance use when indicated).

• Monitor adherence to medications, since nonadherence is a significant risk for relapse.

• To improve functioning and foster the rewards of abstinence, assist patients in developing social, relationship, or vocational skills.

• Attend to patient safety, including attention to human immunodeficiency virus (HIV) and suicidal ideation (both of which have been found to be increased in dually diagnosed patients [Mahler, 1995; Weiss & Hufford, 1999]).

• Have available resources to refer patients to self-help groups for each disorder.

• Discuss with patients what to do and whom to call in case of emergency.

• Provide positive reinforcement for improvements, however small, in each disorder.

• For patients who have had significant periods of recovery, acknowledge these successes and, in a positive way, ask them how they accomplished it. Doing so reminds patients of prior successes and can mitigate the feelings of hopelessness and discouragement that often accompany relapse.

• Take a relapse history to help identify triggers to relapse (e.g., discontinuing medications or treatment, engaging in high-risk behaviors such as socializing where alcohol is present).

• Expect occasional breaks in treatment attendance, and engage in active outreach.

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