General Description of Approach Dual disorders recovery counseling (DDRC)
is an integrated approach to treatment of patients with drug use disorders and comorbid psychiatric disorders. The DDRC model, which integrates individual and group addiction counseling approaches with psychiatric interventions, attempts to balance the focus of treatment so that both the patient’s addiction and psychiatric issues are addressed.
The DDRC model is based on the assumption that there are several treatment phases that patients may go through. These phases are rough guidelines delineating some typical issues patients deal with and include:
Phase 1—Engagement and Stabilization. In this phase, patients are persuaded, motivated, or involuntarily committed to treatment. The main goal of this phase is to help stabilize the acute symptoms of the psychiatric illness and/or the drug use disorder. Another important goal is to motivate patients to continue in treatment once the acute crisis is stabilized or the involuntary commitment expires. Dealing with ambivalence regarding recovery, working through denial of either or both illnesses, and becoming motivated for continued care are other important goals during this phase.
This phase usually takes several weeks, but for some patients it takes longer to become engaged in recovery and to stabilize from acute effects of their dual disorders.
Phase 2—Early Recovery. This phase involves learning to cope with desires to use chemicals; avoiding or coping with people, places, and things that represent high-risk addiction relapse factors; learning to cope with psychiatric symptoms; getting involved in support groups, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Cocaine Anonymous (CA), Rational Recovery (RR), Dual Recovery Anonymous, or mental health support groups; getting the family involved (if indicated); beginning to build structure into life; and identifying problems to work on in recovery.
This phase roughly involves the first 3 months following stabilization. However, some patients take much longer in this phase because they do not comply with treatment, continue to abuse drugs, experience exacerbations of psychiatric symptomology, or experience serious psychosocial problems or crises.
Phase 3—Middle Recovery. In this phase, patients continue working on issues from the previous phase as needed. In addition, patients learn to develop or improve coping skills to deal with intrapersonal and interpersonal issues. Examples of intrapersonal skills include coping with negative affect (anger, depression, emptiness, anxiety) and coping with maladaptive beliefs or thinking. Interpersonal issues that may be addressed during this phase include making amends, improving communication or relationship skills, and further developing social and recovery support systems. This phase also focuses on helping patients cope with persistent symptoms of psychiatric illness; drug use lapses, relapses, or setbacks; and crises related to the psychiatric disorder. It also focuses on helping identify and
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manage relapse warning signs and high-risk relapse factors related to either illness.
The middle recovery phase involves months 4 through 12, although some patients never get much beyond early recovery even after a long time in treatment. Patients who are treated for an initial acute episode of psychiatric illness with pharmacotherapy in addition to DDRC and who do not have a recurrent or persistent mental illness may be tapered off medications during this phase. Patients are usually not tapered off medications until they have several months or longer of significant improvement in psychiatric symptomology.
Phase 4—Late Recovery. This phase, also referred to as the “maintenance phase” of recovery, involves continued work on issues addressed in the middle phase of recovery and work on other clinical issues that emerge. Important intrapersonal or interpersonal issues may be explored in greater depth during this phase for patients who have continued abstinence and remained relatively free of major psychiatric symptoms.
This phase continues beyond year 1. Many patients with chronic or persistent forms of psychiatric illness (e.g., schizophrenia, bipolar disease, recurrent major depression), or severe personality disorders such as borderline personality disorder, often continue active involvement in treatment. Treatment during this phase may involve maintenance pharmacotherapy, supportive DDRC counseling, or some specific form of psychotherapy (e.g., interpersonal psychotherapy). Involvement in support groups continues during this phase of recovery as well.
1.2 Goals and Objectives of Approach The goals of this counseling model are:
1. Achieving and maintaining abstinence from alcohol or other drugs of abuse or, for patients unable or unwilling to work toward
total abstinence, reducing the amount and frequency of use and concomitant biopsychosocial sequelae associated with drug use disorders.
2. Stabilizing acute psychiatric symptoms.
3. Resolving or reducing problems and improving physical, emotional, social, family, interpersonal, occupational, academic, spiritual, financial, and legal functioning.
4. Working toward positive lifestyle change.
5. Early intervention in the process of relapse to either the addiction or the psychiatric disorder.
1.3 Theoretical Rationale/Mechanism of Action The DDRC counseling approach involves a
broad range of interventions:
1. Motivating patients to seek detoxification or inpatient treatment if symptoms warrant, and sometimes facilitating an involuntary commitment for psychiatric care.
2. Educating patients about psychiatric illness, addictive illness, treatment, and the recovery process.
3. Supporting patients’ efforts at recovery and providing a sense of hope regarding positive change.
4. Referring patients for other needed services (case management, medical, social, vocational, economic needs).
5. Helping patients increase self-awareness so that information regarding dual disorders can be personalized.
6. Helping patients identify problems and areas of change.
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7.
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Helping patients develop and improve problemsolving ability and develop recovery coping skills.
Facilitating pharmacotherapy evaluation and compliance. (This requires close collaboration with the team psychiatrist.)
1.4 Agent of Change The DDRC model assumes that change may
occur as a result of the patient-counselor relationship and the team relationship (i.e., counselor, psychiatrist, psychologist, nurse, or other professionals such as case manager or family therapist). A positive therapeutic alliance is seen as critical in helping patients become involved and stay involved in the recovery process. Community support systems, professional treatment groups, and self-help programs also serve as possible agents of positive change for dually diagnosed patients. For the more chronically and persistently mentally ill patients, a case manager may also function as an important agent in the change process.
Although patients have to work on a number of intrapersonal and interpersonal issues as part of long-term recovery, medications can facilitate this process by attenuating acute symptoms, improving mood, or improving cognitive abilities or impulse control. Thus, medications may eliminate or reduce symptoms as well as help patients become more able to address problems during counseling sessions. A severely depressed patient may be unable to focus on learning cognitive or behavioral interventions until he or she experiences a certain degree of remission from symptoms of depression; a floridly psychotic patient will not be able to focus on abstinence from drugs until the psychotic symptoms are under control.
1.5 Conception of Drug Abuse/ Addiction, Causative Factors Both psychiatric and addictive illnesses are
viewed as biopsychosocial disorders. These disorders or diseases are caused or maintained by a variety of biological, psychological, and cultural/social factors. The degree of influence of specific factors may vary among psychiatric disorders.
This DDRC model assumes that there are several possible relationships between psychiatric illness and addiction (Daley et al. 1993; Meyer 1986).
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1. Axis I and Axis II psychopathology may serve as a risk factor for addictive disorders (e.g., the odds of having an addictive disorder among individuals with a mental illness is 2.7 according to the National Institute of Mental Health’s Epidemiologic Catchment Area [ECA] survey).
2. Some psychiatric patients may be more vulnerable than others to the adverse effects of alcohol or other drugs.
3. Addiction may serve as a risk factor for psychiatric illness (e.g., the odds of having a psychiatric disorder among those with a drug use disorder is 4.5 according to the ECA survey).
4. The use of drugs can precipitate an underlying psychiatric condition (e.g., PCP or cocaine use may trigger a first manic episode in a vulnerable individual).
5. Psychopathology may modify the course of an addictive disorder in terms of:
a. Rapidity of course (earlier age depressives experience addiction problems earlier; male-limited alcoholics [25 percent] with antisocial behaviors have earlier onset of addiction compared with milieu-limited alcoholics [Cloninger 1987]).
b. Response to treatment (patients with antisocial or borderline personality disorder often drop out of treatment early).
c. Symptom picture and long-term outcome (high psychiatric severity patients as measured by the Addiction Severity Index (ASI) do worse than low psychiatric severity patients; there is a strong association between relapse and psychiatric impairment among opiate
addicts and some association between relapse and psychiatric impairment among alcoholics [Catalano et al. 1988; McLellan et al. 1985]).
6. Psychiatric symptoms may develop in the course of chronic intoxications (e.g., psychosis may follow PCP use or chronic stimulant use; suicidal tendencies and depression may follow a cocaine crash).
7. Psychiatric symptoms may emerge as a consequence of chronic use of drugs or a relapse (e.g., depression may be caused by an awareness of the losses associated with addiction; depression may follow a drug or alcohol relapse).
8. Drug-using behavior and psychopathological symptoms (whether antecedent or consequent) will become meaningfully linked over the course of time.
9. The addictive disorder and the psychiatric disorder can develop at different points in time and not be linked (e.g., a bipolar patient may become hooked on drugs years after being stable from a manic disorder; an alcoholic may develop panic disorder or major depression long after being sober).
10. Symptoms of one disorder can contribute to relapse of the other disorder (e.g., increased anxiety or hallucinations may lead the patient to alcohol or other drug use to ameliorate symptoms; a cocaine or alcohol binge may lead to depressive symptoms).
2. CONTRAST TO OTHER COUNSELING APPROACHES
2.1 Most Similar Counseling Approaches The DDRC model is most similar to various
aspects of several models of treatment used in addiction counseling, mental health counseling, or
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both. These include individual and group addiction recovery models, the psychoeducational (PE) model, the relapse prevention (RP) model, the cognitive-behavioral model, and the interpersonal model.
2.2 Most Dissimilar Counseling Approaches The DDRC model is dissimilar to the various
forms of dynamic therapies.
3. FORMAT
3.1 Modalities of Treatment The DDRC model can be used in a variety
of group treatments and in individual treatment. It can also be adapted to family treatment.
3.2 Ideal Treatment Setting The DDRC model was primarily developed
for use in a mental health or dual disorders treatment setting. It can be used throughout the continuum of care in inpatient, other residential, partial hospital, and outpatient settings. The specific areas of focus will depend on each patient’s presenting problems and symptoms and the treatment setting. Certain aspects of this model could be adapted and used in addiction treatment settings provided that appropriate training, supervision, and consultation are available for the counselor.
3.3 Duration of Treatment Acute inpatient dual-diagnosis treatment
usually lasts up to 3 weeks. Longer term specialty residential treatment programs may last from several months to a year or more. Partial hospitalization programs usually last from 6 to 12 months. Outpatient treatment lasts 6 months or longer. Recurrent conditions, such as certain depressive disorders and bipolar illness, as well as persistent mental illness such as schizophrenia, typically require ongoing participation in maintenance pharmacotherapy and some type of supportive counseling.
3.4 Compatibility With Other Treatments The DDRC model is very compatible with
pharmacotherapy and family treatment. Many patients require medication to treat psychiatric symptoms. Therefore, medication compliance, the perception of taking medications as a recovering alcoholic or addict, and potential adverse effects of alcohol or other drugs on medication efficacy are important issues to discuss with the patient. Family participation in assessment and treatment is viewed as important and compatible with the DDRC model. The family can:
1. Help provide important information in the assessment process.
2. Provide support to the recovering patient.
3. Address their own questions, concerns, and reactions to coping with the dually diagnosed patient.
4. Address their own problems and issues in treatment sessions or self-help programs.
5. Help identify early signs of addiction relapse or psychiatric recurrence and point these out to the recovering dually diagnosed family member.
A combination of family PE programs, family counseling sessions, and family support programs can be used to help families. Referrals for assessment of serious problems (psychiatric, drug abuse, behavioral) among specific family members can also be initiated as necessary (e.g., a child of a patient who is suicidal, very depressed, or getting into trouble at school can be referred for a psychiatric evaluation).
3.5 Role of Self-Help Programs Self-help programs are very important in the
DDRC model of treatment. All patients are educated regarding self-help programs and linked up to specific programs. The self-help programs recommended may include any of the following
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for a given patient: AA, NA, CA, and other addiction support groups such as RR or Women for Sobriety; dual-recovery support groups; and mental health support groups. However, this model does not assume that a patient cannot recover without involvement in a 12-step group or that failure to attend 12-step groups is a sign of resistance. The DDRC model also assumes that some patients may use some of the tools of recovery of self-help programs even if they do not attend meetings. Sponsorship, recovery literature, slogans, and recovery clubs are also seen as very helpful aspects of recovery for dually diagnosed patients.
4. COUNSELOR CHARACTERISTICS AND TRAINING
4.1 Educational Requirements The educational requirements are variable for
inpatient staff and depend on the professional discipline’s requirements. Formal education of inpatient staff include M.D., Ph.D., master’s, bachelor’s, and associate degrees. Training in fields such as nursing may vary as well and include M.S.N., B.S.N., R.N., and L.P.N. Outpatient therapists tend to have at least a master’s degree or higher and function more autonomously than inpatient staff.
4.2 Training, Credentials, and Experience Required To effectively provide counseling services to
dually diagnosed patients, the counselor needs to have a broad knowledge of assessment and treatment of dual disorders. Specific areas with which the counselor should be familiar, at a minimum, include the following:
1. Psychiatric illnesses (types, causes, symptoms, and effects).
2. Drug use disorders (trends in drug abuse; types and effects of various drugs; causes, symptoms, and effects of addiction).
3. The relationship between the psychiatric illness and drug use.
4. The recovery process for dual disorders.
5. Self-help programs (for addiction, mental health disorders, and dual disorders).
6. Family issues in treatment and recovery.
7. Relapse (precipitants, warning signs, and RP strategies for both disorders).
8. Specialized psychosocial treatment approaches for various psychiatric disorders (e.g., treatments for posttraumatic stress disorder, obsessive-compulsive disorder).
