Treatment Of Dually Diagnosed Patients A Heterogeneous Population

Since "dually diagnosed" patients comprise a heterogeneous population, it follows that their treatment should perhaps reflect that heterogeneity (Weiss, Mirin, & Frances, 1992); a "one size fits all" approach therefore will likely not be optimal. However, providing group treatments tailored to patients with some degree of diagnostic homogeneity (e.g., patients with bipolar disorder and SUDs) can be a difficult strategy to implement if one is unable to recruit a large enough clinical population for these groups. Similarly, even within diagnostically homogeneous groups, considerable heterogeneity in illness severity and functioning may still exist. Ries, Sloan, and Miller (1997) have suggested a conceptual approach that divides dually diagnosed patients into four major subgroups, according to the severity (i.e., major or minor) of each disorder. Although this is a somewhat crude way to classify patients, it may be helpful in developing an outpatient group treatment program for dually diagnosed patients.

An additional consideration is that not all patients are similar in terms of insight regarding their SUD, nor are they similarly ready to address it. Thus, patients who are undecided whether or not to address their substance use may do better in a group focused on resolving that issue, as opposed to a group in which all participants are actively engaged in treatment and making lifestyle changes to support sobriety. We know of no studies, however, that have tested this idea empirically. It is possible, for example, that having a mix of patient severity levels in one group allows patients the opportunity to learn from those further along in their recovery. This is a central principle of Alcoholics Anonymous (AA), and appears to have strong anecdotal support. Treatments that focus on particular dual diagnoses (e.g., bipolar SUD patients) also have not been directly compared to more general thematic groups (e.g., dual diagnosis groups that are more general, encompassing a wide variety of diagnoses). Thus, it remains an empirical question how the known heterogeneity of such patients should best be addressed within the realistic constraints of specific clinical settings.

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