Psychosocial treatments with the potential for broad applicability across several dual-diagnosis populations have also been developed. With the exception of cognitive therapy, most originated in the addiction literature but have demonstrated some efficacy in treating both disorders when adapted specifically for dually diagnosed populations. Below, we briefly describe several of the more common psychosocial interventions studied in populations with co-occurring SUDs and psychiatric disorders.
Cognitive-behavioral therapy (CBT), developed by Beck, Rush, Shaw, and Emery (1979), has been adapted for the treatment of substance abuse (Beck, Wright, Newman, & Liese, 1993). When adapted to specific dually diagnosed populations (e.g., PTSD), additional techniques include the identification of cognitive distortions associated with both disorders (e.g., getting high now as a "reward" for having been deprived in the past), identifying meanings of substance use in the context of PTSD (e.g., as revenge against an abuser), and teaching new coping skills (e.g., setting boundaries) (Najavits et al., 1996).
Relapse prevention therapy (RPT), developed by Marlatt and Gordon (1985), is a form of CBT that focuses on understanding the process of relapse in order to prevent it. RPT can be used as an adjunctive therapy or as a treatment in and of itself. When modified to address dually diagnosed individuals, preventing relapse from both disorders is emphasized. For example, RPT modified for patients with co-occurring bipolar disorder and SUDs (Weiss, Najavits, & Greenfield, 1999; Weiss et al., 2000) teaches patients about triggers for both substance use and bipolar disorder (e.g., erratic sleep behaviors, associating with the wrong people, nonadherence to one's medication regimen).
Motivational interviewing (MI), developed by Miller and Rollnick (1991, 2002), utilizes theory derived from several psychotherapeutic models: systems, client-centered, cognitive-behavioral, and social psychology. MI is also called motivational enhancement, because it is often a brief treatment conducted in as few as two sessions, sometimes aimed at helping the patient accept other psychotherapy (e.g., CBT). Guidelines for modifying MI in dually diagnosed patients with psychotic disorders have been published (Carey et al., 2001; Martino et al., 2002). Recent randomized pilot trials of MI in diverse dually diagnosed populations suggest that it may improve the likelihood of making the transition to outpatient treatment (Swanson, Pantalon, & Cohen, 1999), improve SUD outcomes (Graeber et al., 2003), and decrease psychiatric hospitalization (Daley & Zuckoff, 1998).
The transtheoretical stages-of-change model (Prochaska, DiClemente, & Norcross, 1992, 1994) describes a sequential process of five stages of change in recovery for patients with SUDs: precontemplation, contemplation, preparation, action, and maintenance. Osher and Kofoed (1989) have articulated a model similar to stages of change for dually diagnosed patients with severe psy chiatric disorders. Adaptations to the stages-of-change model for SPMI dual-diagnosis populations have also been developed, and some have been empirically tested for reliability and validity (Carey, Carey, Maisto, & Purnine, 2002; Velasquez, Carbonari, & DiClemente, 1999) with promising results (Carey et al., 2002; Ziedonis & Trudeau, 1997). Pilot work of a family intervention adapted from the stages-of-change model for this population has also shown promise (Mueser & Fox, 2002).
Twelve-step drug counseling derives directly from the principles of AA and has been adapted for use by professional alcohol and drug counselors (a necessary adaptation, since AA was designed as a self-help group not led by professionals). Two types of treatment emphasize these principles: individual drug counseling (Mercer & Woody, 1999) and 12-step facilitation (TSF) (Nowinski, Baker, & Carroll, 1995). TSF is used by all of the studies described below. Several trials have compared outcomes of dually diagnosed patients treated with TSF groups with outcomes among those treated with various other psychosocial treatments (i.e., CBT, RPT, dialectical behavioral therapy [DBT], or behavioral skills group) (Brooks & Penn, 2003; Fisher & Bentley, 1996; Jerrell & Ridgely, 1995; Linehan, 1993; Linehan et al., 2002; McKay et al., 2002; Ouimette, Gima, Moos, & Finney, 1999). Among them, only one found improved SUD outcomes in TSF versus the comparison integrated treatment (Brooks & Penn, 2003). However, in that study, the TSF group also experienced worsening health and employment status, and psychiatric hospitaliza-tion, compared to the group of patients receiving integrated treatment.
Contingency management (CM) interventions reinforce behavior that meets specific, clearly defined, and observable goals (Petry, 2000) such as abstinence (Higgins et al., 1994), medication adherence (Liebson, Tommasello, & Bigelow, 1978), therapy attendance (Helmus, Rhodes, Haber, & Downey, 2001), or completion of treatment goals (Petry, Martin, Cooney, & Kranzler, 2000). Recent empirical evaluations using CM as an adjunctive treatment in dually diagnosed populations suggest that it may offer some benefit in attendance, but its impact on SUD outcomes has been mixed (Helmus, Saules, Schoener, & Roll, 2003; Sigmon, Steingard, Badger, Anthony, & Higgins, 2000).
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