Substance Abuse Treatment 

For Persons With 

Co-Occurring Disorders 

A Treatment 

Improvement 

Protocol 

TIP 

42 
Substance Abuse Treatment 

For Persons With 

Co-Occurring Disorders 

A Treatment 

Improvement 

Protocol 

TIP 

42 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

1 Choke Cherry Road

Rockville, MD 20857
Acknowledgments

This publication was prepared under contract

number 270­99­7072 by the Knowledge

Application Program (KAP), a Joint Venture of

The CDM Group, Inc., and JBS International,

Inc., for the Substance Abuse and Mental Health

Services Administration (SAMHSA), U.S.

Department of Health and Human Services

(HHS). Karl D. White, Ed.D., and Andrea

Kopstein, Ph.D., M.P.H., served as the

Contracting Officer’s Representatives.

Disclaimer

The views, opinions, and content of this publication are those of the author and do not

necessarily reflect the views, opinions, or

policies of SAMHSA or HHS.

Public Domain Notice

All material appearing in this report is in the

public domain and may be reproduced or

copied without permission from SAMHSA.

Citation of the source is appreciated.

However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of

Communications, SAMHSA, HHS.

Electronic Access and Copies

of Publication

This publication may be ordered from or 

downloaded from SAMHSA’s Publications 

Ordering Web page at http://store.samhsa.gov. 

Or, please call SAMHSA at 1­877­SAMHSA­7 

(1­877­726­4727) (English and Español). 

Recommended Citation

Substance Abuse and Mental Health Services

Administration. Substance Abuse Treatment

for Persons With Co­Occurring Disorders.

Treatment Improvement Protocol (TIP)

Series, No. 42. HHS Publication No. (SMA)

13­3992. Rockville, MD: Substance Abuse

and Mental Health Services Administration,

2005.

Originating Office

Quality Improvement and Workforce

Development Branch, Division of Services

Improvement, Center for Substance Abuse

Treatment, Substance Abuse and Mental

Health Services Administration, 1 Choke

Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 13­3992

First Printed 2005

Revised 2007, 2008, 2011, 2012, and 2013 

ii Acknowledgments
Please share your thoughts about this publication by completing a brief online survey at:

https://www.surveymonkey.com/r/KAPPFS

The survey takes about 7 minutes to complete and is anonymous.

Your feedback will help SAMHSA develop future products.
Contents 

What Is a TIP? ............................................................................................................ix
 


Consensus Panel...........................................................................................................xi
 


KAP Expert Panel and Federal Government Participants ..................................................xiii
 


Foreword ...................................................................................................................xv
 


Executive Summary....................................................................................................xvii
 


Chapter 1—Introduction ................................................................................................1
 


Overview......................................................................................................................1
 


The Evolving Field of Co-Occurring Disorders ......................................................................2
 


Important Developments That Led to This TIP .....................................................................4
 


Organization of This TIP................................................................................................16
 


Chapter 2—Definitions, Terms, and Classification Systems for Co-Occurring Disorders...........21
 


Overview ....................................................................................................................21
 


Terms Related to Substance Use Disorders..........................................................................22
 


Terms Related to Mental Disorders ...................................................................................23
 


Terms Related to Clients.................................................................................................26
 


Terms Related to Treatment ............................................................................................27
 


Terms Related to Programs .............................................................................................32
 


Terms Related to Systems ...............................................................................................33
 


Chapter 3—Keys to Successful Programming...................................................................37
 


Overview ....................................................................................................................37
 


Guiding Principles ........................................................................................................38
 


Delivery of Services.......................................................................................................41
 


Improving Substance Abuse Treatment Systems and Programs ................................................48
 


Workforce Development and Staff Support .........................................................................55
 


Chaper 4—Assessment .................................................................................................65
 


Overview ....................................................................................................................65
 


Screening and Basic Assessment for COD ...........................................................................66
 


The Assessment Process .................................................................................................71
 


Chaper 5—Strategies for Working With Clients With Co-Occurring Disorders......................101
 


Overview...................................................................................................................101
 


Guidelines for a Successful Therapeutic Relationship With a Client Who Has COD ....................102
 


Techniques for Working With Clients With COD .................................................................112
 


Chapter 6—Traditional Settings and Models ...................................................................137
 


Overview...................................................................................................................137
 


Essential Programming for Clients With COD ....................................................................138
 


Outpatient Substance Abuse Treatment Programs for Clients With COD ..................................143
 


Residential Substance Abuse Treatment Programs for Clients With COD ..................................161
 


iii 
Chapter 7—Special Settings and Specific Populations ......................................................183
 


Overview...................................................................................................................183
 


Acute Care and Other Medical Settings.............................................................................184
 


Dual Recovery Mutual Self-Help Programs........................................................................190
 


Specific Populations.....................................................................................................197
 


Chapter 8—A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues.............213
 


Overview...................................................................................................................213
 


Cross-Cutting Issues.....................................................................................................214
 


Personality Disorders...................................................................................................220
 


Mood Disorders and Anxiety Disorders.............................................................................226
 


Schizophrenia and Other Psychotic Disorders ....................................................................231
 


Attention-Deficit/Hyperactivity Disorder (AD/HD) ..............................................................235
 


Posttraumatic Stress Disorder (PTSD) .............................................................................238
 


Eating Disorders .........................................................................................................240
 


Pathological Gambling..................................................................................................246
 


Conclusion.................................................................................................................248
 


Chapter 9—Substance-Induced Disorders ......................................................................249
 


Overview...................................................................................................................249
 


Description ................................................................................................................249
 


Diagnostic Considerations .............................................................................................252
 


Case Studies: Identifying Disorders .................................................................................253
 


Appendix A—Bibliography..........................................................................................255
 


Appendix B—Acronyms..............................................................................................309
 


Appendix C—Glossary of Terms...................................................................................313
 


Appendix D—Specific Mental Disorders: Additional Guidance for the Counselor ..................325
 


Overview...................................................................................................................325
 


Suicidality .................................................................................................................326
 


Nicotine Dependence....................................................................................................333
 


Personality Disorders (Overview) ....................................................................................348
 


Borderline Personality Disorder .....................................................................................353
 


Antisocial Personality Disorder ......................................................................................359
 


Mood and Anxiety Disorders ..........................................................................................369
 


Schizophrenia and Other Psychotic Disorders ....................................................................385
 


Attention Deficit-Hyperactivity Disorder (AD/HD) ..............................................................402
 


Posttraumatic Stress Disorder ........................................................................................408
 


Eating Disorders .........................................................................................................417
 


Pathological Gambling..................................................................................................425
 


Appendix E—Emerging Models....................................................................................437
 


Part I: Addresses for Models Referenced in the Text............................................................437
 


Part II: Other Emerging Models......................................................................................439
 


Programs ..................................................................................................................457
 


iv Contents 
Appendix F—Common Medications for Disorders ...........................................................459
 

Pharmacologic Risk Factors...........................................................................................459
 

A Stepwise Treatment Model ..........................................................................................461
 

Psychotherapeutic Medications 2004: What Every Counselor Should Know...............................463
 

Appendix G—Screening and Assessment Instruments .......................................................487
 

Addiction Severity Index (ASI) .......................................................................................487
 

The Alcohol Use Disorders Identification Test (AUDIT)........................................................488
 

Beck Depression Inventory­II (BDI­II) .............................................................................488
 

CAGE Questionnaire....................................................................................................489
 

Circumstances, Motivation, and Readiness Scales (CMR Scales) .............................................489
 

Clinical Institute Withdrawal Assessment (CIWA­Ar) ...........................................................490
 

The Drug Abuse Screening Test (DAST)............................................................................490
 

Global Appraisal of Individual Needs (GAIN).....................................................................491
 

Level of Care Utilization System (LOCUS).........................................................................491
 

Michigan Alcoholism Screening Test (MAST)......................................................................492
 

M.I.N.I. Plus .............................................................................................................492
 

Psychiatric Research Interview for Substance and Mental Disorders (PRISM) ...........................493
 

Readiness to Change Questionnaire .................................................................................493
 

Recovery Attitude and Treatment Evaluator (RAATE) .........................................................494
 

Structured Clinical Interview for DSM­IV Disorders (SCID­IV)..............................................494
 

Substance Abuse Treatment Scale (SATS) .........................................................................495
 

University of Rhode Island Change Assessment (URICA) ......................................................495
 

Appendix H—Sample Screening Instruments..................................................................497
 

Mental Health Screening Form­III...................................................................................498
 

Simple Screening Instrument for Substance Abuse ..............................................................499
 

Appendix I—Selected Sources of Training .....................................................................513
 

Sources of Training on Addiction Disorders.......................................................................513
 

Sources of Training on Mental Health ..............................................................................515
 

Sources of Training on Co­Occurring Disorders..................................................................515
 

Listservs and Discussion Groups on Co­Occurring Disorders .................................................516
 

Appendix J—Dual Recovery Mutual Self­Help Programs and 

Other Resources for Consumers and Providers...............................................................519
 

Dual Recovery 12­Step Fellowships..................................................................................519
 

Supported Mutual Help for Dual Recovery........................................................................520
 

Other Resources for Consumers and Providers...................................................................521
 

Appendix K—Confidentiality .......................................................................................523
 

Federal Laws and the Right to Confidentiality ....................................................................523
 

Appendix L—Resource Panel ......................................................................................527 

Appendix M—Cultural Competency and Diversity Network Participants..............................531
 

Appendix N—Field Reviewers......................................................................................533
 

Appendix O—Acknowledgments...................................................................................539
 

Index ......................................................................................................................541
 

SAMHSA TIPs and Publications...................................................................................561
 

Contents v
Figures



1-1 Persons With Alcohol, Drug Abuse, or Mental Disorder in the Past Year ............................5
 


1-2 Rates of Antisocial Personality, Depression, and Anxiety Disorder by Drug Dependency ........8
 


1-3 Substance Abuse Treatment Facilities Offering Special Programs for Clients With COD........11
 


2-1 Level of Care Quadrants........................................................................................29
 


3-1 Six Guiding Principles in Treating Clients With COD....................................................38
 


3-2 Levels of Program Capacity in Co-Occurring Disorders.................................................44
 


3-3 A Vision of Fully Integrated Treatment for COD..........................................................45
 


3-4 The Co-Occurring Collaborative of Southern Maine .....................................................49
 


3-5 Assessing the Agency’s Potential To Serve Clients With COD ..........................................51
 


3-6 Financing a Comprehensive System of Care for People With COD ...................................52
 


3-7 Essential Attitudes and Values for Clinicians Who Work With Clients Who Have COD .........57
 


3-8 Examples of Basic Competencies Needed for Treatment of Persons With COD ....................58
 


3-9 Six Areas of Intermediate-Level Competencies Needed for the Treatment 
 

of Persons With COD ..........................................................................................59
 


3-10 Examples of Advanced Competencies in the Treatment of Clients With COD ......................60



3-11 Treatment Planning and Documentation Issues for Mental and Substance Use Disorders.......61
 


3-12 Certification in Health Professions...........................................................................63
 


3-13 Reducing Staff Turnover in Programs for Clients With COD ..........................................64
 


4-1 Assessment Considerations .....................................................................................74
 


4-2 Sample Treatment Plan for George T. (Case 2) ............................................................96
 


4-3 Considerations in Treatment Matching .....................................................................97
 


5-1 Stages of Change ................................................................................................116
 


5-2 Motivational Enhancement Approaches ...................................................................117
 


5-3 A Four-Session Motivation-Based Intervention ..........................................................119
 


5-4 Checklist for Designing CM Programs......................................................................123
 


6-1 Engagement Interventions ....................................................................................165
 


6-2 Principles of Implementation ................................................................................166
 


6-3 Sample Training and Technical Assistance Curriculum ................................................167
 


6-4 Residential Interventions......................................................................................172
 


6-5 TC Modifications for Persons With COD..................................................................174
 


7-1 Criteria for Major Depressive Episode.....................................................................206
 


D-1 Key Questions in a Suicide Risk Review ...................................................................330
 


D-2 DSM-IV Criteria for Nicotine Withdrawal ................................................................341
 


D-3 The Fagerstrom Test for Nicotine Dependence...........................................................342
 


D-4 Brief Strategies for Smoking Cessation.....................................................................344
 


D-5 Brief Strategies 2. Components of Presriptive Relapse Prevention..................................348
 


D-6 Characteristics of People With Antisocial and Borderline Personality Disorders ................350
 


D-7 Step Work Handout for Clients With BPD................................................................360



D-8 Counseling Tips for Clients With APD .....................................................................367
 


D-9 Antisocial Thinking-Error Work ............................................................................368
 


D-10 Drugs That Precipitate or Mimic Mood Disorders.......................................................373
 


D-11 Engaging the Client With Chronic Psychosis .............................................................391
 


D-12 Biopsychosocial Assessment of High-Risk Conditions ..................................................392
 


D-13 AD/HD Symptom Cluster: Inattention .....................................................................403
 


D-14 AD/HD Symptom Cluster: Hyperactivity-Impulsivity ..................................................403
 


D-15 Grounding: A Coping Skill for Clients With Emotional Pain .........................................413
 


D-16 How Are Eating Disorders and Substance Use Disorders Related?..................................421
 


vi Contents 
D-17 General and Specific Screening Questions for Persons With Possible Eating Disorders ........422
 


D-18 Diagnostic Criteria for Pathological Gambling Compared to Substance 
 

Dependence Criteria..........................................................................................426
 


D-19 Comparison of Action and Escape Pathological Gamblers ............................................427
 


H-1 Sources for Items Included in the Simple Screening Instrument for Substance Abuse..........503
 


H-2 Simple Screening Instrument for Substance Abuse Interview Form.................................506
 


H-3 Simple Screening Instrument for Substance Abuse Self-Administered Form......................509
 


H-4 Scoring for the Simple Screening Instrument for Substance Abuse .................................511
 


Advice to the Counselor Boxes 

Chapter 2



Antisocial Personality Disorders.......................................................................................24
 


Psychotic Disorders.......................................................................................................25
 


Mood and Anxiety Disorders ...........................................................................................25
 


Chapter 4



Do’s and Don’ts of Assessment for COD .............................................................................67
 


Chapter 5



Forming a Therapeutic Alliance ......................................................................................103
 


Maintaining a Recovery Perspective.................................................................................105
 


Managing Countertransference .......................................................................................106
 


Monitoring Psychiatric Symptoms ...................................................................................107
 


Using Culturally Appropriate Methods .............................................................................111
 


Using Contingency Management Techniques.......................................................................125
 


Using Relapse Prevention Methods ..................................................................................130
 


Chapter 6



Recommendations for Providing Essential Services for People With COD .................................141
 


Treatment Principles From ACT .....................................................................................157
 


Treatment Principles From ICM .....................................................................................159
 


Recommended Treatment and Services From the MTC Model ................................................175
 


Chapter 7



Working With Homeless Clients With COD ........................................................................200
 


Providing Community Supervision for Offenders With COD ..................................................202
 


Treatment Principles and Services for Women With COD .....................................................210
 


Chapter 8



Counseling a Client Who Is Suicidal.................................................................................215
 


Counseling a Client With Borderline Personality Disorder ....................................................222
 


Counseling a Client With an Anxiety or Mood Disorder ........................................................229
 


Counseling a Client With a Psychotic Disorder ...................................................................234
 


Counseling a Client Who Has AD/HD ...............................................................................237
 


Counseling a Client With PTSD ......................................................................................241
 


Counseling a Client With an Eating Disorder......................................................................245
 


Counseling a Client With Pathological Gambling Disorder.....................................................248 
 

Contents vii 
What Is a TIP?

Treatment Improvement Protocols (TIPs) are developed by the Center

for Substance Abuse Treatment (CSAT), part of the Substance Abuse

and Mental Health Services Administration (SAMHSA) within the U.S.

Department of Health and Human Services (HHS). Each TIP involves

the development of topic­specific best­practice guidelines for the prevention and treatment of substance use and mental disorders. TIPs draw on

the experience and knowledge of clinical, research, and administrative

experts of various forms of treatment and prevention. TIPs are distributed to facilities and individuals across the country. Published TIPs

can be accessed via the Internet at http://store.samhsa.gov.

Although each consensus­based TIP strives to include an evidence base

for the practices it recommends, SAMHSA recognizes that behavioral

health is continually evolving, and research frequently lags behind the

innovations pioneered in the field. A major goal of each TIP is to convey

"front­line" information quickly but responsibly. If research supports a

particular approach, citations are provided.

ix
Consensus Panel 

Chair 

Stanley Sacks, Ph.D. 

Director 

Center for the Integration of Research and 

Practice 

National Development and Research 

Institutes, Inc. 

New York, New York 

Co-Chair 

Richard K. Ries, M.D. 

Director/Professor 

Outpatient Mental Health Services 

Dual Disorder Programs 

Harborview Medical Center 

Seattle, Washington 

Workgroup Leaders 

Donna Nagy McNelis, Ph.D. 

Director, Behavioral Healthcare Education 

Associate Professor, Psychiatry 

Drexel University 

School of Medicine 

Philadelphia, Pennsylvania 

David Mee-Lee, M.D., FASAM 

DML Training and Consulting 

Davis, California 

James L. Sorenson, Ph.D. 

Department of Psychiatry 

San Francisco General Hospital 

San Francisco, California 

Douglas Ziedonis, M.D. 

Director, Addiction Services 

University Behavioral Healthcare System 

Piscataway, New Jersey 

Joan E. Zweben, Ph.D. 

Executive Director 

The 14th Street Clinic and Medical Group 

East Bay Community Recovery Project 

University of California 

Berkeley, California 

Panelists 

Betty Blackmon, M.S.W., J.D. 

Parker-Blackmon and Associates 

Kansas City, Missouri 

Steve Cantu, LCDC, CADAC, RAS 

Clinical Program Coordinator 

South Texas Rural Health Services, Inc. 

Cotulla, Texas 

Catherine S. Chichester, M.S.N., R.N., CS 

Executive Director 

Co-Occurring Collaborative of Southern 

Maine 

Portland, Maine 

Colleen Clark, Ph.D. 

Research Associate 

Department of Community Mental Health 

University of South Florida 

Tampa, Florida 

Christie A. Cline, M.D., M.B.A. 

Medical Director 

Behavioral Health Sciences Division 

New Mexico Department of Health 

Santa Fe, New Mexico 

Raymond Daw, M.A. 

Executive Director 

Na’nizhoozhi Center, Inc. 

Gallup, New Mexico 

xi 
Sharon C. Ekleberry, L.C.S.W., L.S.A.T.P, 

B.C.D. 

Division Director 

Adult Outpatient Services 

Fairfax County Mental Health Services 

Fairfax/Falls Church Community Services 

Board 

Centreville, Virginia 

Byron N. Fujita, Ph.D. 

Senior Psychologist 

Clackamas County Mental Health Center 

Oregon City, Oregon 

Lewis E. Gallant, Ph.D. 

Executive Director 

National Association of State Alcohol and 

Drug Abuse Directors, Inc. 

Washington, DC 

Michael Harle, M.H.S. 

President/Executive Director 

Gaudenzia, Inc. 

Norristown, Pennsylvania 

Michael W. Kirby, Jr., Ph.D. 

Chief Executive Officer 

Arapahoe House, Inc. 

Thornton, Colorado 

Kenneth Minkoff, M.D. 

Medical Director 

Choate Health Management 

Woburn, Massachusetts 

Lisa M. Najavits, Ph.D. 

Associate Professor of Psychology 

Harvard Medical School/McLean Hospital 

Belmont, Massachusetts 

Tomas A. Soto, Ph.D. 

Director 

Behavioral Sciences 

The CORE Center 

Chicago, Illinois 

The Chair and Co-Chair would like to thank Kenneth Minkoff, M.D., for his valuable contributions to chapter 4 of this TIP. 

Special thanks go to Douglas Ziedonis, M.D., for providing content on nicotine; Donna Nagy 

McNelis, Ph.D., for providing content for the workforce development section; Tim Hamilton, 

for providing content for the section on dual recovery self-help groups in chapter 7; Theresa 

Moyers, Ph.D., for her critical review of the motivational interviewing section; George A. 

Parks, Ph.D., for his input into the relapse prevention section; Cynthia M. Bulik, Ph.D., for 

writing the section on eating disorders; Lisa M. Najavits, Ph.D., for her contributions to the 

PTSD section; Loreen Rugle, Ph.D., for writing the section on gambling disorders; Barry S. 

Brown, Ph.D., for providing consultation to the Chair; and Jo Scraba for her editorial assistance to the Chair. 

xii Consensus Panel 
KAP Expert Panel and Federal 

Government Participants 

Barry S. Brown, Ph.D. 

Adjunct Professor 

University of North Carolina at Wilmington 

Carolina Beach, North Carolina 

Jacqueline Butler, M.S.W., LISW, LPCC, 

CCDC III, CJS 

Professor of Clinical Psychiatry 

College of Medicine 

University of Cincinnati 

Cincinnati, Ohio 

Deion Cash 

Executive Director 

Community Treatment and Correction 

Center, Inc. 

Canton, Ohio 

Debra A. Claymore, M.Ed.Adm. 

Owner/Chief Executive Officer 

WC Consulting, LLC 

Loveland, Colorado 

Carlo C. DiClemente, Ph.D. 

Chair 

Department of Psychology 

University of Maryland Baltimore County 

Baltimore, Maryland 

Catherine E. Dube, Ed.D. 

Independent Consultant 

Brown University 

Providence, Rhode Island 

Jerry P. Flanzer, D.S.W., LCSW, CAC 

Chief, Services 

Division of Clinical and Services Research 

National Institute on Drug Abuse 

Bethesda, Maryland 

Michael Galer, D.B.A. 

Chairman of the Graduate School of Business 

University of Phoenix—Greater Boston 

Campus 

Braintree, Massachusetts 

Renata J. Henry, M.Ed. 

Director 

Division of Alcoholism, Drug Abuse, 

and Mental Health 

Delaware Department of Health and Social 

Services 

New Castle, Delaware 

Joel Hochberg, M.A. 

President 

Asher & Partners 

Los Angeles, California 

Jack Hollis, Ph.D. 

Associate Director 

Center for Health Research 

Kaiser Permanente 

Portland, Oregon 

Mary Beth Johnson, M.S.W. 

Director 

Addiction Technology Transfer Center 

University of Missouri—Kansas City 

Kansas City, Missouri 

Eduardo Lopez, B.S. 

Executive Producer 

EVS Communications 

Washington, DC 

Holly A. Massett, Ph.D. 

Academy for Educational Development 

Washington, DC 

xiii 
Diane Miller 

Chief 

Scientific Communications Branch 

National Institute on Alcohol Abuse 

and Alcoholism 

Bethesda, Maryland 

Harry B. Montoya, M.A. 

President/Chief Executive Officer 

Hands Across Cultures 

Espanola, New Mexico 

Richard K. Ries, M.D. 

Director/Professor 

Outpatient Mental Health Services 

Dual Disorder Programs 

Seattle, Washington 

Gloria M. Rodriguez, D.S.W. 

Research Scientist 

Division of Addiction Services 

NJ Department of Health and Senior Services 

Trenton, New Jersey 

Everett Rogers, Ph.D. 

Center for Communications Programs 

Johns Hopkins University 

Baltimore, Maryland 

Jean R. Slutsky, P.A., M.S.P.H. 

Senior Health Policy Analyst 

Agency for Healthcare Research & Quality 

Rockville, Maryland 

Nedra Klein Weinreich, M.S. 

President 

Weinreich Communications 

Canoga Park, California 

Clarissa Wittenberg 

Director 

Office of Communications and Public Liaison 

National Institute of Mental Health 

Kensington, Maryland 

Consulting Members 

Paul Purnell, M.A. 

Social Solutions, L.L.C. 

Potomac, Maryland 

Scott Ratzan, M.D., M.P.A., M.A. 

Academy for Educational Development 

Washington, DC 

Thomas W. Valente, Ph.D. 

Director, Master of Public Health Program 

Department of Preventive Medicine 

School of Medicine 

University of Southern California 

Alhambra, California 

Patricia A. Wright, Ed.D. 

Independent Consultant 

Baltimore, Maryland 

xiv KAP Expert Panel and Federal Government Participants 
               

         

                   

                 

                     

             

            

         

                 

                      

         

                   

                   

                   

                 

                       

                     

Foreword

The Treatment Improvement Protocol (TIP) series fulfills the Substance

Abuse and Mental Health Services Administration’s (SAMHSA’s) mission

to improve prevention and treatment of substance use and mental disorders by providing best practices guidance to clinicians, program administrators, and payers. TIPs are the result of careful consideration of all

relevant clinical and health services research findings, demonstration

experience, and implementation requirements. A panel of non­Federal

clinical researchers, clinicians, program administrators, and patient

advocates debates and discusses their particular area of expertise until

they reach a consensus on best practices. This panel’s work is then

reviewed and critiqued by field reviewers.

The talent, dedication, and hard work that TIPs panelists and reviewers

bring to this highly participatory process have helped bridge the gap

between the promise of research and the needs of practicing clinicians

and administrators to serve, in the most scientifically sound and effective

ways, people in need of behavioral health services. We are grateful to all

who have joined with us to contribute to advances in the behavioral

health field.

Pamela S. Hyde, J.D.

Administrator

Substance Abuse and Mental Health Services Administration

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM 

Director

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services Administration

xv
Executive Summary 

For purposes of this TIP, co-occurring disorders refers to co-occurring 

substance use (abuse or dependence) and mental disorders. Clients said 

to have co-occurring disorders have one or more disorders relating to 

the use of alcohol and/or other drugs of abuse as well as one or more 

mental disorders. A diagnosis of co-occurring disorders (COD) occurs 

when at least one disorder of each type can be established independent 

of the other and is not simply a cluster of symptoms resulting from the 

one disorder. Many may think of the typical person with COD as having 

a severe mental disorder combined with a severe substance use disorder, 

such as schizophrenia combined with alcohol dependence. However, 

counselors working in addiction agencies are more likely to see persons 

with severe addiction combined with mild- to moderate-severity mental 

disorders; an example would be a person with alcohol dependence combined with a depressive disorder or an anxiety disorder. Efforts to provide treatment that will meet the unique needs of people with COD have 

gained momentum over the past 2 decades in both substance abuse treatment and mental health services settings. 

Throughout this TIP, the term “substance abuse” refers to both substance abuse and substance dependence (as defined by the Diagnostic 

and Statistical Manual of Mental Disorders, 4th edition, Text Revision 

[DSM-IV-TR] [American Psychiatric Association 2000]) and encompasses the use of both alcohol and other psychoactive substances. Though 

unfortunately ambiguous, this term was chosen partly because the lay 

public, politicians, and many substance abuse treatment professionals 

commonly use “substance abuse” to describe any excessive use of any 

addictive substance. Readers should attend to the context in which the 

term occurs to determine the range of possible meanings; in most cases, 

however, the term refers to all substance use disorders described by the 

DSM-IV. It should be noted, however, that although nicotine dependency 

is recognized as a disorder in DSM-IV, an important difference between 

tobacco addiction and other addictions is that tobacco’s chief effects are 

medical rather than behavioral, and, as such, it is not treated as substance abuse in this TIP. Nonetheless, because of the high numbers of 

xvii 
the COD population addicted to nicotine as 

well as the devastating health consequences of 

tobacco use, nicotine dependency is included as 

an important cross-cutting issue for people with 

substance use disorders and mental illness. 

Terms for mental disorders may have somewhat different lay and professional definitions. 

For example, while most people might become 

depressed or anxious briefly around a life 

stress, this does not mean that they have a 

“mental disorder” as is used in this text. 

Because the DSM-IV is the national standard 

for definitions of mental disorders, it is used in 

this TIP. In certain States, however, only certain trained professionals “officially” can diagnose either a mental or substance use disorder. 

In the late 1970s, practitioners began to recognize that the presence of substance abuse in 

combination with mental disorders had profound and troubling implications for treatment 

outcomes. This growing awareness has culminated in today’s emphasis on the need to recognize and address the interrelationship of these 

disorders through new approaches and appropriate adaptations of traditional treatment. In 

the decades from the 1970s to the present, substance abuse treatment programs typically 

reported that 50 to 75 percent of their clients 

had COD, while corresponding mental-health 

settings cited proportions of 20 to 50 percent. 

During the same period of time, a body of 

knowledge has evolved that clarifies the treatment challenges presented by the combination 

of substance use and mental disorders and illuminates the likelihood of poorer outcomes for 

such clients in the absence of targeted treatment efforts. 

The treatment and research communities have 

not been passive in the face of this challenge. 

Innovative strategies have emerged and been 

tested, and the treatment population has been 

defined more precisely. Findings have shown 

that many substance abuse treatment clients 

with less serious mental disorders do well with 

traditional substance abuse treatment methods, 

while those with more serious mental disorders 

need intervention modifications and additions 

to enhance treatment effectiveness and, in most 

instances, to result in successful treatment outcomes. 

The Quadrants of Care, developed by the 

National Association of State Alcohol and Drug 

Abuse Directors (NASADAD) and the National 

Association of State Mental Health Program 

Directors (NASMHPD), is a useful classification of service coordination by severity in the 

context of substance abuse and mental health 

settings. The NASADAD–NASMHPD fourquadrant framework provides a structure for 

fostering consultation, collaboration, and integration among drug abuse and mental health 

treatment systems and providers to deliver 

appropriate care to every client with COD. 

Although the material in this TIP relates to all 

four quadrants, the TIP is designed primarily 

to provide guidance for addiction counselors 

working in quadrant II and III settings. The 

four categories of COD are 

•		Quadrant I: Less severe mental disorder/less 

severe substance disorder 

•		Quadrant II: More severe mental 

disorder/less severe substance disorder 

•		Quadrant III: Less severe mental 

disorder/more severe substance disorder 

•		Quadrant IV: More severe mental disorder/more severe substance disorder 

The American Society of Addiction Medicine 

(ASAM) also has developed a client placement 

system to facilitate effective treatment. The 

ASAM Patient Placement Criteria (ASAM 

PPC-2R) describe three types of substance 

abuse programs for people with COD: addiction only services, dual diagnosis capable, and 

dual diagnosis enhanced. This TIP employs a 

related system that classifies both substance 

abuse and mental health programs as basic, 

intermediate, and advanced in terms of their 

progress toward providing more integrated 

care. Further, counselors or other readers who 

use this TIP will have beginning, intermediate, 

or advanced backgrounds and experience in 

COD, and, therefore, different needs. The TIP 

is structured to meet the needs of addiction 

counselors with basic backgrounds as well as 

xviii Executive Summary 
the differing needs of those with intermediate 

and advanced backgrounds. 

The integration of substance abuse treatment 

and mental health services for persons with 

COD has become a major treatment initiative. 

Integrated treatment coordinates substance 

abuse and mental health interventions to treat 

the whole person more effectively; the term 

refers broadly to any mechanism by which 

treatment interventions for COD are combined 

within a primary treatment relationship or service setting. As such, integrated treatment 

reflects the longstanding concern within substance abuse treatment programs for treating 

the whole person, and recognizes the importance of ensuring that entry into any one system can provide access to all needed systems. 

As developed in the substance abuse treatment 

field, the recovery perspective acknowledges 

that recovery is a long-term process of internal 

change in which progress occurs in stages, an 

understanding critical to treatment planning. 

In preparing a treatment plan, the clinician 

should recognize that treatment takes place in 

different settings (e.g., residential and outpatient) over time, and that much of the recovery 

process typically occurs outside of, or following, treatment (e.g., through participation in 

mutual self-help groups). Practitioners often 

divide treatment into phases, usually including 

engagement, stabilization, primary treatment, 

and continuing care (also known as aftercare). 

Use of these phases enables the clinician 

(whether within the substance abuse or mental 

health treatment system) to apply coherent, 

stepwise approaches in developing and using 

treatment protocols. 

This TIP identifies key elements of programming for COD in substance abuse treatment 

agencies; the paragraphs that follow provide an 

outline of these essential elements. While the 

needs and functioning of substance abuse treatment are accentuated, the elements described 

have relevance for mental health agencies and 

other service systems that seek to coordinate 

mental health and substance abuse services for 

their clients who need both. 

Treatment planning begins with screening and 

assessment. The screening process is designed 

to identify those clients seeking substance abuse 

treatment who show signs of mental health 

problems that warrant further attention. Easyto-use screening instruments will accomplish 

this purpose and can be administered by counseling staff with minimal preparation. 

A basic assessment consists of gathering information that will provide evidence of COD and 

mental and substance use disorder diagnoses; 

assess problem areas, disabilities, and 

strengths; assess readiness for change; and 

gather data to guide decisions regarding the 

necessary level of care. Intake information consists of the following categories and items: 

•		Background is described by obtaining data 

on family; relevant cultural, linguistic, gender, and sexual orientation issues; trauma 

history; marital status; legal involvement 

and financial situation; health; education; 

housing status; strengths and resources; and 

employment. 

•		Substance use is established by age of first 

use, primary drugs used, patterns of drug 

use (including information related to diagnostic criteria for abuse or dependence), 

and past or current treatment. It is important to identify periods of abstinence of 30 

days or longer to isolate the mental health 

symptoms, treatment, and disability 

expressed during these abstinent periods. 

•		Psychiatric problems are elaborated by 

determining both family and client histories 

of psychiatric problems (including diagnosis, 

hospitalization, and other treatments), current diagnoses and symptoms, and medications and medication adherence. It is important to identify past periods of mental health 

stability, determine past successful treatment for mental disorders, and discover the 

nature of substance use disorder issues arising during these stable periods. Identification of any current treatment providers 

enables vitally important information sharing and cooperation. 

•		Integrated assessment identifies the interactions among the symptoms of mental disorExecutive Summary xix 
ders and substance use, as well as the interactions of the symptoms of substance use 

disorders and mental health symptoms. 

Integrated assessment also considers how all 

the interactions relate to treatment experiences, especially stages of change, periods of 

stability, and periods of crisis. 

Diagnosis is an important part of the assessment process. The TIP provides a discussion of 

mental disorders selected from the DSM-IV-TR 

and the diagnostic criteria for each disorder. 

Key information about substance abuse and 

particular mental disorders is distilled, and 

appropriate counselor actions and approaches 

are recommended for the substance abuse 

treatment client who manifests symptoms of 

one or more of these mental disorders. The 

consensus panel recognizes that addiction 

counselors are not expected to diagnose mental 

disorders. The limited aims of providing this 

material are to increase substance abuse treatment counselors’ familiarity with mental disorder terminology and criteria and to provide 

advice on how to proceed with clients who 

demonstrate the symptoms of these disorders. 

The use of proper medication is an essential 

program element, helping clients to stabilize 

and control their symptoms, thereby increasing 

their receptivity to other treatment. Pharmacological advances over the past few decades have 

produced more effective psychiatric medications with fewer side effects. With the support 

of better medication regimens, many people 

with serious mental disorders who once would 

have been institutionalized, or who would have 

been too unstable for substance abuse treatment, have been able to participate in treatment, make progress, and lead more 

productive lives. To meet the needs of this population, the substance abuse treatment counselor needs better understanding of the signs 

and symptoms of mental disorders and access 

to medical support. The counselor’s role is first 

to provide the prescribing physician with an 

accurate description of the client’s behavior 

and symptoms, which ensures that proper medication is chosen, and then to assist the client in 

adhering to the medication regimen. The substance abuse counselor and program can, and 

often do, employ peers or the peer community 

to help and support individual efforts to follow 

prescription instructions. 

Several other features complete the list of 

essential components of treatment for COD, 

including enhanced staffing that incorporates 

professional mental health specialists, psychiatric consultation, or an onsite psychiatrist 

(for assessment, diagnosis, and medication); 

psychoeducational classes (e.g., mental disorders and substance abuse, relapse prevention) 

that provide increased awareness about the 

disorders and their symptoms; onsite double 

trouble groups to discuss the interrelated problems of mental and substance use disorders, 

which will help to identify triggers for relapse; 

and participation in community-based dual 

recovery mutual self-help groups, which afford 

an understanding, supportive environment and 

a safe forum for discussing medication, mental 

health, and substance abuse issues. 

Treatment providers are advised to view clients 

with COD and their treatment in the context of 

their culture, ethnicity, geographic area, 

socioeconomic status, gender, age, sexual orientation, religion, spirituality, and any physical 

or cognitive disabilities. The provider especially needs to appreciate the distinctive ways in 

which a client’s culture may view disease or disorder, including COD. Using a model of disease 

familiar and culturally relevant to the client 

can help communication and facilitate treatment. 

In addition to the essential elements described 

above, several well-developed and successful 

strategies from the substance abuse field are 

being adapted for COD. The TIP presents 

those strategies (briefly noted in the following 

paragraphs) found to have promise for effective treatment of clients with COD. 

Motivational Interviewing (MI) is a client-centered, directive method for enhancing intrinsic 

motivation to change (by exploring and resolving ambivalence) that has proven effective in 

helping clients clarify goals and commit to 

change. MI has been modified to meet the spexx Executive Summary 
cial circumstances of clients with COD, with 

promising results from initial studies to 

improve client engagement in treatment. 

Contingency Management (CM) maintains that 

the form or frequency of behavior can be 

altered through the introduction of a planned 

and organized system of positive and negative 

consequences. It should be noted that many 

counselors and programs employ CM principles 

informally by rewarding or praising particular 

behaviors and accomplishments. Similarly, CM 

principles are applied formally (but not necessarily identified as such) whenever the attainment of a level or privilege is contingent on 

meeting certain behavioral criteria. 

Demonstration of the efficacy of CM principles 

for clients with COD is still needed. 

Cognitive–Behavioral Therapy (CBT) is a general therapeutic approach that seeks to modify 

negative or self-defeating thoughts and behaviors, and is aimed at achieving change in both. 

CBT uses the client’s cognitive distortions as 

the basis for prescribing activities to promote 

change. Distortions in thinking are likely to be 

more severe with people with COD who are, by 

definition, in need of increased coping skills. 

CBT has proven useful in developing these coping skills in a variety of clients with COD. 

Relapse Prevention (RP) has proven to be a 

particularly useful substance abuse treatment 

strategy and it appears adaptable to clients 

with COD. The goal of RP is to develop the 

client’s ability to recognize cues and to intervene in the relapse process, so lapses occur less 

frequently and with less severity. RP endeavors 

to anticipate likely problems, and then helps 

clients to apply various tactics for avoiding 

lapses to substance use. Indeed, one form of 

RP treatment, Relapse Prevention Therapy, 

has been specifically adapted to provide integrated treatment of COD, with promising 

results from some initial studies. 

Because outpatient treatment programs are 

widely available and serve the greatest number 

of clients, it is imperative that these programs 

use the best available treatment models to 

reach the greatest possible number of persons 

with COD. In addition to the essential elements 

and the strategies described above, two outpatient models from the mental health field have 

been valuable for outpatient clients with both 

substance use and serious mental disorders: 

Assertive Community Treatment (ACT) and 

Intensive Case Management (ICM). 

ACT programs, historically designed for clients 

with serious mental illness, employ extensive 

outreach activities, active and continuing 

engagement with clients, and a high intensity of 

services. ACT emphasizes multidisciplinary 

teams and shared decisionmaking. When working with clients who have COD, the goals of the 

ACT model are to engage them in helping relationships, assist them in meeting basic needs 

(e.g., housing), stabilize them in the community, and ensure that they receive direct and integrated substance abuse treatment and mental 

health services. Randomized trials with clients 

having serious mental and substance use disorders have demonstrated better outcomes on 

many variables for ACT compared to standard 

case management programs. 

The goals of ICM are to engage individuals in a 

trusting relationship, assist in meeting their 

basic needs (e.g., housing), and help them 

access and use brokered services in the community. The fundamental element of ICM is a low 

caseload per case manager, which translates 

into more intensive and consistent services for 

each client. ICM has proven useful for clients 

with serious mental illness and co-occurring 

substance use disorders. (The consensus panel 

notes that direct translation of ACT and ICM 

models from the mental health settings in which 

they were developed to substance abuse settings 

is not self-evident. These initiatives likely must 

be modified and evaluated for application in 

such settings.) 

Residential treatment for substance abuse 

occurs in a variety of settings, including long­

(12 months or more) and short-term residential 

treatment facilities, criminal justice institutions, and halfway houses. In many substance 

abuse treatment settings, psychological disturbances have been observed in an increasing 

Executive Summary xxi 
proportion of clients over time; as a result, 

important initiatives have been developed to 

meet their needs. 

The Modified Therapeutic Community (MTC) 

is a promising residential model from the substance abuse field for those with substance use 

and serious mental disorders. The MTC adapts 

the principles and methods of the therapeutic 

community to the circumstances of the client, 

making three key alterations: increased flexibility, more individualized treatment, and 

reduced intensity. The latter point refers especially to the conversion of the traditional 

encounter group to a conflict resolution group, 

which is highly structured, guided, of very low 

emotional intensity, and geared toward achieving self-understanding and behavior change. 

The MTC retains the central feature of TC 

treatment; a culture is established in which 

clients learn through mutual self-help and affiliation with the peer community to foster change 

in themselves and others. A series of studies 

has established better outcomes and benefit 

cost of the MTC model compared to standard 

services. A need for more verification of the 

MTC approach remains. 

Because acute and primary care settings 

encounter chronic physical diseases in combination with substance use and mental disorders, treatment models appropriate to medical 

settings are emerging, two of which are 

described in the TIP. In these and other settings, it is particularly important that administrators assess organizational readiness for 

change prior to implementing a plan of integrated care. The considerable differences 

between the medical and social service cultures 

should not be minimized or ignored; rather, 

opportunities should be provided for relationship and team building. 

Within the general population of persons with 

COD, the needs of a number of specific subgroups can best be met through specially 

adapted or designed programs. These include 

persons with specific disorders (such as bipolar 

disorder) and groups with unique requirements 

(such as women, the homeless, and clients in 

the criminal justice system). The two categories 

often overlap; for example, a number of recovery models are emerging for women with substance use disorders who are survivors of trauma, many of whom have posttraumatic stress 

disorder. The TIP highlights a number of 

promising approaches to treatment for particular client groups, while recognizing that further 

development is needed, both of disorder-specific interventions and of interventions targeted to 

the needs of specific populations. 

Returning to life in the community after residential placement is a major undertaking for 

clients with COD, and relapse is an ever-present danger. Discharge planning is important to 

maintain gains achieved through residential or 

outpatient treatment. Depending on program 

and community resources, a number of continuing care (aftercare) options may be available 

for clients with COD who are leaving treatment. These options include mutual self-help 

groups, relapse prevention groups, continued 

individual counseling, psychiatric services 

(especially important for clients who will continue to require medication), and ICM to continue monitoring and support. A carefully 

developed discharge plan, produced in collaboration with the client, will identify and relate 

client needs to community resources, ensuring 

the supports needed to sustain the progress 

achieved in treatment. 

During the past decade, dual recovery mutual 

self-help approaches have been developed for 

individuals affected by COD and are becoming 

an important vehicle for providing continued 

support in the community. These approaches 

apply a broad spectrum of personal responsibility and peer support principles, often 

employing 12-Step methods that provide a 

planned regimen of change. The clinician can 

help clients locate a suitable group, find a 

sponsor (ideally one who also has COD and is 

at a late stage of recovery), and become comfortable in the role of group member. 

Continuity of care refers to coordination of 

care as clients move across different service 

systems and is characterized by three features: 

xxii Executive Summary 
consistency among primary treatment activities 

and ancillary services, seamless transitions 

across levels of care (e.g., from residential to 

outpatient treatment), and coordination of present with past treatment episodes. Because 

both substance use and mental disorders typically are long-term chronic disorders, continuity of care is critical; the challenge in any system of care is to institute mechanisms to ensure 

that all individuals with COD experience the 

benefits of continuity of care. 

The consensus panel recognizes that the role of 

the client (the consumer) with COD in the 

design of, and advocacy for, improved services 

should continue to expand. The consensus 

panel recommends that program design and 

development activities of agencies serving 

clients with COD continue to incorporate consumer and advocacy groups. These groups help 

to further the refinement and responsiveness of 

the treatment program, thus enhancing clients’ 

self-esteem and investment in their own treatment. 

All good treatment depends on a trained staff. 

The consensus panel underscores the importance of creating a supportive environment for 

staff and encouraging continued professional 

development, including skills acquisition, values clarification, and competency attainment. 

An organizational commitment to staff development is necessary to implement programs successfully and to maintain a motivated and 

effective staff. It is essential to provide consistently high-quality and supportive supervision, 

favorable tuition reimbursement and release 

time policies, appropriate pay and health/ 

retirement benefits, helpful personnel policies 

that bolster staff well-being, and incentives or 

rewards for work-related achievements. 

Together, these elements help create the infrastructure needed for quality service. 

The consensus panel supports and encourages 

the development of a unified substance abuse 

and mental health approach to co-occurring 

disorders. Recognizing that system integration 

is difficult to achieve and that the need for 

improved COD services in substance abuse 

treatment agencies is urgent, the panel recommends that, at this stage, the emphasis be 

placed on assisting the substance abuse treatment system in the development of increased 

internal capability to treat individuals with 

COD effectively. A parallel effort should be 

undertaken in the mental health system, with 

the two systems continuing to work cooperatively on services to individual clients. 

Much has been accomplished in the field of 

COD in the last 10 years, and the knowledge 

acquired is ready for broader dissemination 

and application. The importance of the transfer and application of knowledge and technology has likewise become better understood. The 

consensus panel emphasizes the need for new 

government initiatives that improve services by 

promoting innovative technology transfer 

strategies using material from this TIP and 

from other resources (e.g., the Substance 

Abuse and Mental Health Services 

Administration’s [SAMHSA’s] Report to 

Congress on the Treatment and Prevention of 

Co-Occurring Substance Abuse and Mental 

Disorders and SAMHSA’s Center for Mental 

Health Service’s Co-Occurring Disorders: 

Integrated Dual Disorders Treatment 

Implementation Resource Kit) are adapted and 

shaped to the particular program context and 

circumstances. 

Executive Summary xxiii 
1 Introduction 

In This 

Chapter... 

The Evolving Field of 
 

Co-Occurring Disorders



Important Developments



That Led to This TIP



Organization of This TIP



Overview 

Over the past few decades, practitioners and researchers increasingly 

have recognized the link between substance abuse and mental disorders. Treatment Improvement Protocol (TIP) 9, Assessment and 

Treatment of Patients With Coexisting Mental Illness and Alcohol and 

Other Drug Abuse (Center for Substance Abuse Treatment [CSAT] 

1994a), answered the treatment field’s need for an overview of diagnostic criteria, assessment, psychopharmacology, specific mental disorders, and the need for linkage between the mental health services 

system and substance abuse treatment system. 

Subsequent to TIP 9, research has provided a more in-depth understanding of co-occurring substance use and mental disorders—how 

common they are, the multiple problems they create, and the impact 

they have on treatment and treatment outcome. As knowledge of cooccurring disorders (COD) continues to evolve, new challenges arise: 

How do we treat specific populations such as the homeless and those in 

our criminal justice system? What is the role of housing? What about 

those with specific mental disorders such as posttraumatic stress disorder? Where is the best locus for treatment? Can we build an integrated 

system of care? The main purpose of this TIP is to provide addiction 

counselors and other practitioners with this state-of-the-art information on the rapidly advancing field of co-occurring substance use and 

mental disorders. 

Following a discussion of the evolving field of co-occurring disorders, 

this chapter addresses the developments that led to this TIP. It then 

describes the scope of this TIP (both what is included and what is 

excluded by design), its intended audience, and the basic approach 

that has guided the selection of strategies, techniques, and models 

highlighted in the text. The organization of the TIP is laid out for the 

reader, with the components of each chapter and appendix described 

in an effort to help users of the TIP quickly locate subjects of immediate interest. 

1 
The Evolving Field of 

Co-Occurring Disorders 

Today’s emphasis on the relationship between 

substance use and mental disorders dates to 

the late 1970s, when practitioners increasingly became aware of the implications of these 

disorders, when occurring together, for treatment outcomes. The association between 

depression and substance abuse was particularly striking and became the subject of several early studies (e.g., Woody and Blaine 

1979). In the 1980s and 1990s, however, both 

the substance abuse and mental health communities found that a wide range of mental 

disorders were associated with substance 

abuse, not just depression (e.g., De Leon 

1989; Pepper et al. 1981; Rounsaville et al. 

1982b; Sciacca 1991). During this period, 

studies conducted in substance abuse programs typically reported that 50 to 75 percent 

of clients had some type of co-occurring mental disorder (although not usually a severe 

mental disorder) while studies in mental 

health settings reported that between 20 and 

50 percent of their clients had a co-occurring 

substance use disorder. (See Sacks et al. 

1997b for a summary of studies and Compton 

et al. 2000 for a more recent study.) 

The multiple studies reflect the extent to 

which COD constitutes a clinical concern. At 

the same time, however, these studies varied 

in that they (1) were conducted in an array of 

settings and on a range of sample sizes from 

68 to 20,291, (2) used different measures and 

criteria for determining a disorder, and (3) 

reported on different time periods (i.e., either 

lifetime or current, or both). This diversity in 

reporting can produce differing estimates and 

suggests a need to address the broad range of 

survey and analytic strategies used to generate estimates. Further work to clarify the 

type, severity, and clinical significance of cooccurring disorders can contribute to an 

improved understanding of the phenomenon 

and treatment. Nevertheless, it is important 

that, in spite of those differences, there is a 

consistency in reporting significant rates of 

disorder across all studies. 

Researchers not only found a link between 

substance abuse and mental illness, they also 

found the dramatic impact the complicating 

presence of substance abuse may have on the 

course of treatment for mental illness. One 

study of 121 clients with psychoses found that 

those with substance abuse problems (36 percent) spent twice as many days in the hospital 

over the 2 years prior to treatment as clients 

without substance abuse problems (Crome 

1999; Menezes et al. 1996). These clients 

often have poorer outcomes, such as higher 

rates of HIV infection, relapse, rehospitalization, depression, and suicide risk (Drake et 

al. 1998b; Office of the Surgeon General 

1999). 

Researchers also have clearly demonstrated 

that substance abuse treatment for clients 

with co-occurring mental illness and substance use disorders can be beneficial—even 

for clients with serious mental symptoms. For 

example, the National Treatment Improvement Evaluation Study (NTIES) found 

marked reductions in suicidality the year following substance abuse treatment compared 

to the year prior to treatment for both male 

and female clients and nonabused women. 

Suicide attempts declined about four fifths 

for both the 3,037 male clients and the 1,374 

female clients studied (Karageorge 2001). 

Many clients in traditional substance abuse 

treatment settings who had mild to moderate 

mental disorders were found to do well with 

traditional substance abuse treatment methods (Hser et al. 2001; Hubbard et al. 1989; 

Joe et al. 1995; Simpson et al. 2002; Woody et 

al. 1991). However, modifications designed to 

address mental disorders may further 

enhance treatment effectiveness and can be 

essential for people with severe mental disorders. This TIP will discuss the modifications 

and approaches practitioners have found to 

be helpful. For examples, see the sections on 

suicide assessment and intervention in chapter 8 and appendix D. 

2 Introduction 
Just as the field of treatment for substance 

use and mental disorders has evolved to 

become more precise, so too has the terminology used to describe people with both substance use and mental disorders. The term 

co-occurring disorders replaces the terms 

dual disorder or dual diagnosis. These latter 

terms, though used commonly to refer to the 

combination of substance use and mental disorders, are confusing in that they also refer 

to other combinations of disorders (such as 

mental disorders and mental retardation). 

Furthermore, the terms suggest that there are 

only two disorders occurring at the same 

time, when in fact there may be more. For 

purposes of this TIP, co-occurring disorders 

refers to co-occurring substance use (abuse or 

dependence) and mental disorders. Clients 

said to have co-occurring disorders have one 

or more disorders relating to the use of alcohol and/or other drugs of abuse as well as one 

or more mental disorders. A diagnosis of cooccurring disorders occurs when at least one 

disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from the one disorder. (See chapter 2 for more discussion of terminology used in this TIP.) 

New models and strategies are receiving 

attention and encouraging treatment innovation (Anderson 1997; De Leon 1996; Miller 

1994a; Minkoff 1989; National Advisory 

Council [NAC] 1997; Onken et al. 1997; 

Osher and Drake 1996). Reflecting the 

increased interest in issues surrounding effective treatment for this population, the 

American Society of Addiction Medicine 

(ASAM) added substantial new sections on 

clients with COD to an update of its patient 

placement criteria. These sections refine criteria both for placing clients with COD in 

treatment and for establishing and operating 

programs to provide services for such clients 

(ASAM 2001). 

In another important development, the 

National Association of State Alcohol and 

Drug Abuse Directors (NASADAD) began 

surveying its members about effective treatIntroduction 

ment of clients with COD in their States 

(Gustafson et al. 1999). In addition, 

NASADAD has joined with the National 

Association of State Mental Health Program 

Directors (NASMHPD) (NASMHPDNASADAD 1999, 2000) and other collaborators in a series of national efforts designed to 

• Foster improvement in treatment by emphasizing the importance of knowledge 

of both mental 

health and substance abuse treatment when working 

with clients for 

whom both issues 

are relevant. 

• Provide a classification of treatment 

settings to facilitate 

systematic planning, 

consultations, collaborations, and 

integration. 

• Reduce the stigma 

associated with both 

disorders and 

increase the acceptance of substance 

abuse and mental 

health concerns as a 

standard part of 

healthcare information gathering. 

Researchers have 

clearly demonstrated that 

substance abuse 

treatment of 

clients with cooccurring mental 

illness and substance use disorders can be beneficial. 

These efforts are slowly changing the way that the public, policymakers, and substance abuse counselors view mental illness. Still, stigma attached to mental illness remains. One topic worth mentioning is 

the public perception that people with mental 

illness are dangerous and pose a risk of violence. However, stu dies have shown that the 

public’s fear is greater than the actual risk, 

and that often, people with mental disorders 

are not particularly violent; it is when substance abuse is added that violence can ensue. 

For example, Steadman et al. (1998) found that 

substance abuse symptoms significantly raised 

3 
the rate of violence in both individuals with 

mental illness and those without mental illness. 

This research adds support to the importance 

of treating both mental illness and substance 

abuse. 

In recent years, dissemination of knowledge 

has been widespread. Numerous books and 

hundreds of articles have been published, 

from counseling manuals and instruction 

(Evans and Sullivan 2001; Pepper and 

Massaro 1995) to database analysis of linkage 

among treatment systems and payors (Coffey 

et al. 2001). Several annual “dual diagnosis” 

conferences emerged. One of the most longstanding is the annual conference on The 

Person With Mental Illness and Substance 

Abuse, hosted by MCP Hahnemann 

University (now Drexel University), which 

began in 1988. 

In spite of these developments, individuals 

with substance use and mental disorders commonly appear at facilities that are not prepared to treat them. They may be treated for 

one disorder without consideration of the 

other disorder, often “bouncing” from one 

type of treatment to another as symptoms of 

one disorder or another become predominant. Sometimes they simply “fall through the 

cracks” and do not receive needed treatment. 

This TIP captures the current state-of-the-art 

treatment strategies to assist counselors and 

treatment agencies in providing appropriate 

services to clients with COD. 

Important 

Developments That 

Led to This TIP 

Important developments in a number of areas 

pointed to the need for a revised TIP on cooccurring disorders. Among the factors that 

contributed to the need for this document are 

the availability of significant data on the 

prevalence of COD, the emergence of new 

treatment populations with COD (such as 

people who are homeless, people with 

HIV/AIDS, and persons in the criminal justice system), and changes in treatment delivery (including an increasing number of programs serving persons with COD). The following section provides a summary of data relevant to each of these key areas. 

The Availability of Prevalence 

and Other Data 

Prevalence and other data on COD have 

established the scope and impact of the problem, and the need for appropriate treatment 

and services. Four key findings are borne out 

by prevalence and other available data, each 

of which is important in understanding the 

challenges of providing effective treatment to 

this population. 

(1) COD are common in the general adult 

population, though many individuals 

with COD go untreated. 

National surveys suggest COD are common in 

the adult population. For example, the 

National Survey on Drug Use and Health 

(NSDUH) reports that in 2002, 4 million 

adults met the criteria for both serious mental 

illness (SMI) and substance dependence and 

abuse. NSDUH information is based on a 

sample of 67,500 American civilians aged 12 

or older in noninstitutionalized settings 

(Office of Applied Studies [OAS] 2003b). The 

NSDUH defined SMI as having at some time 

during the past year a diagnosable mental, 

behavioral, or emotional disorder that met 

the criteria specified in the Diagnostic and 

Statistical Manual of Mental Disorders, 4th 

edition (DSM-IV) (American Psychiatric 

Association 1994) and resulted in functional 

impairment that substantially interfered with 

or limited one or more major life activities. 

The NSDUH classification scheme was not 

diagnosis specific, but function specific. 

Results from the survey are highlighted 

below. 

• SMI is highly correlated with substance 

dependence or abuse. Among adults with 

SMI in 2002, 23.2 percent were dependent on 

or abused alcohol or illicit drugs, while the 

rate among adults without SMI was only 8.2 

percent. Among adults with substance depen4 Introduction 
dence or abuse, 20.4 percent had SMI; the 

rate of SMI was 7 percent among adults who 

were not dependent on or abusing a substance. 

•Among adults who used an illicit drug in the

past year, 17.1 percent had SMI in that

year, while the rate was 6.9 percent among

adults who did not use an illicit drug.

Conversely, among adults with SMI, 28.9

percent used an illicit drug in the past year

while the rate was 12.7 percent among those

without SMI (OAS 2003b).

•SMI was correlated with binge alcohol use

(defined as drinking five or more drinks on

the same occasion on at least one day in the

past 30 days). Among adults with SMI, 28.8

percent were binge drinkers, while 23.9

percent of adults with no SMI were binge

drinkers.

Earlier, the National Comorbidity Study (NCS) 

reported 1991 information on mental disorders 

and substance abuse or dependence in a sample 

of 8,098 American civilians aged 15 to 54 in 

noninstitutionalized settings. Figure 1-1 shows 

estimates from the NCS of the comparative 

number of any alcohol, drug abuse, or mental 

disorder (52 million), any mental disorder (40 

million), any substance abuse/dependence disorder (20 million), and both mental disorder 

and substance abuse/dependence (8 million) in 

the past year. 

In a series of articles derived from the NCS, 

Kessler and colleagues give a range of estimates related to both the lifetime and 12­

month prevalence of COD (Kessler et al. 

1994, 1996a, b, 1997). They estimate that 10 

million Americans of all ages and in both 

institutional and noninstitutional settings 

have COD in any given year. Kessler et al. 

Figure 1-1 

Persons With Alcohol, Drug Abuse, or Mental Disorder in the Past Year 

(See Endnote1

) 

U.S. Population, Age 15 to 54, 1991 29.5%



(52 Million)
 30 – 

22.9% 25 – (40 Million) 

20 – 

15 – 11.3% 

(20 Million) 

10 – 

4.7% 

(8 Million) 5 –



0 

 Any Alcohol, 

Drug Abuse, 

or 

Mental 

Disorder 

Any Mental 

Disorder 

Any Substance 

Abuse/ 

Dependency 

Co-existing Mental 

Disorder and 

Substance Abuse 

Dependency 

Source: Kessler et al. 1994. Table 2 and unpublished data from the survey. 

Introduction 5 
also estimate the lifetime prevalence of COD 

(not shown in Figure 1-1, which relates only 

the prevalence in the past 12 months) (1996a, 

p. 25) as follows: “...51 percent of those with 

a lifetime addictive disorder also had a lifetime mental disorder, compared to 38 percent 

in the ECA.” (The ECA—Epidemiologic 

Catchment Area study—predated the NCS 

study; this National Institute of Mental 

Health study of 20,291 people was representative of the total U.S. community and institutional populations [Regier et al. 1990]). 

Comparative figures for individuals with COD 

whose addictive disorders involve alcohol versus drugs are also available. Fifty-three percent of the respondents with lifetime 

alcohol abuse or 

dependence also

had one or more 

lifetime mental disorders. For respondents with lifetime 

illicit drug 

abuse/dependence, 

59 percent also had 

a lifetime mental 

disorder, and 71 

percent of those 

with lifetime illicit

drug abuse/ dependence had alcohol

abuse or dependence over their

lifetime (Office of 

the Inspector 

General 1995). 

Research suggests 

that the likelihood 

of seeking treatment is strongly 

increased in the		

presence of at 

least one co-occurring condition. 

A recent first report from the National 

Comorbidity Survey Replication, conducted 

between February 2001 and December 2002 

(Kessler and Walters 2002), provides more 

precise information on rates of specific disorders. For example, rates of major depressive 

disorder were reported at 6.6 percent in the 

general population in the last year, or an estimated number between 13.1 and 14.2 million 

people (Kessler et al. 2003b). Additional data 

from a new and expanded NCS survey are 

now available (e.g., Breslau et al. 2004a, b; 

Kessler 2003; Kessler et al. 2003a ). 

Research suggests that the likelihood of seeking treatment is strongly increased in the 

presence of at least one co-occurring condition. The National Longitudinal Alcohol 

Epidemiologic Study (NLAES)—a nationwide 

household survey of 42,862 respondents aged 

18 or older conducted by the National 

Institute on Alcohol Abuse and Alcoholism— 

reveals that a large increase in treatment for 

an alcohol disorder and a drug disorder 

occurs when there is a co-occurring “major 

depressive disorder” (Grant 1997). NCS data 

suggest that people with more than two disorders are more likely to receive treatment than 

those with “only” two. People with three or 

more diagnosable conditions were the most 

likely to be severely impaired and to require 

hospitalization (NAC 1997). 

While people with co-occurring disorders are 

more likely to seek treatment, research consistently shows a gap between the number of 

people who are identified in a survey as having a disorder and the number of people 

receiving any type of treatment. Even of those 

with three or more disorders, a troubling 60 

percent never received any treatment (Kessler 

et al. 1994; NAC 1997). Based on NLAES 

data, Grant (1997, p. 13) notes that one of 

the most interesting results of the survey is 

the “sheer number of respondents with alcohol and drug use disorders missing from the 

treated population. Only 9.9 percent and 8.8 

percent of the respondents classified with 

past-year alcohol and drug use disorders, 

respectively, sought treatment.” 

(2) Some evidence supports an 

increased prevalence of people 

with COD and of more programs for 

people with COD. 

NASADAD conducts voluntary surveys of 

State Alcohol and Drug Abuse Agencies and 

produces the State Alcohol and Drug Abuse 

Profile (SADAP) reports. In 1996, NASADAD 

asked the States to describe any special programs in their States for clients with COD 

6 Introduction 
and to provide any available fiscal year (FY) 

1995 statistics on the number of “dually diagnosed” clients treated (Gustafson et al. 1997). 

Forty-one States plus Palau, Puerto Rico, 

and the U.S. Virgin Islands responded. About 

3 years later, 31 States responded to a 

request for detailed statistics on the number 

of persons admitted in FYs 1996 and 1997 to 

programs for treatment of COD (Gustafson et 

al. 1999). In general, examination of SADAP 

State profiles for information related to COD 

suggests about a 10 percent increase since the 

NASADAD survey in both the number of people with COD entering treatment and in the 

number of programs in many States over that 

3-year period (Gustafson et al. 1999). 

The 2002 National Survey of Substance 

Abuse Treatment Services (N-SSATS) indicated that about 49 percent of 13,720 facilities 

nationwide reporting substance abuse services 

offered programs or groups for those with 

COD (OAS 2003a). However, only 38 percent 

of the 8,292 responding facilities that focused 

primarily on substance abuse offered such 

COD programming. Sixty-three percent of the 

1,126 responding mental health services that 

offered substance abuse services offered COD 

programs or groups. About 70 percent of the 

3,440 facilities that have a mix of mental 

health and substance abuse treatment services offer COD programs or groups. 

Still it must be kept in mind that of all the 

approximately 1.36 million clients in treatment for substance use disorders in 2002, 

about 68 percent were treated in facilities 

whose primary focus was substance abuse services and 23 percent were treated in facilities 

whose focus was a mix of both mental health 

and substance abuse services. Only 4 percent 

of these individuals were in facilities whose 

primary focus was the provision of mental 

health services. 

(3) Rates of mental disorders increase as 

the number of substance use disorders increases, further complicating 

treatment. 

In their analysis of data from a series of 

studies supported by the National Institute on 

Drug Abuse, the Drug Abuse Treatment 

Outcome Study (DATOS), Flynn et al. (1996) 

demonstrate that the likelihood of mental disorders rises with the increasing number of 

substance dependencies. Participating clients 

were assessed according to DSM-III-R criteria 

(Diagnostic and Statistical Manual for Mental 

Disorders, 3d edition revised) for lifetime 

antisocial personality, major depression, generalized anxiety disorder, and/or any combination of these disorders. 

DATOS was a national study of clients entering more than 90 substance abuse treatment 

programs in 11 metropolitan areas, mainly 

during 1992 (Flynn et al. 1997). Of the initial 

intake sample of 10,010 clients, 7,402 completed an intake and a clinical assessment 

interview and met DSM-III-R criteria for 

dependence on alcohol, cocaine, and/or heroin. Figure 1-2 (p. 8) shows a general trend of 

increase in the rates of DSM-III-R lifetime 

antisocial personality disorder, major depression, and generalized anxiety disorder as the 

number of substance dependencies involving 

alcohol, heroin, and cocaine increases (except 

for the relationship between alcohol dependence only and major depression and generalized anxiety). Since the use of multiple drugs 

is common in those with substance use disorders, treatment is further complicated for 

these people by the greater incidence of mental disorders that accompanies multiple drug 

use. 

(4) Compared to people with mental 

or substance use disorders alone, 

people with COD are more likely 

to be hospitalized. Some evidence suggests that the rate of 

hospitalization for people with 

COD is increasing. 

According to Coffey and colleagues, the rate of 

hospitalization for clients with both a mental 

and a substance use disorder was more than 20 

times the rate for substance-abuse–only clients 

and five times the rate for mentalIntroduction 7 
Figure 1-2 

Rates of Antisocial Personality, Depression, and Anxiety Disorder by 

Drug Dependency (%). Taken From the Drug Abuse Treatment Outcome 

Study (DATOS) 

Drug dependency Antisocial personality Major depression Generalized anxiety 

Alcohol only 34.7 17.8 5.5 

Heroin only 27 7 2 

Heroin and alcohol 46.3 13.2 3.2 

Cocaine only 30.4 8.4 2.7 

Cocaine and alcohol 47 13.6 4.7 

Cocaine and heroin 44 10.8 2.2 

Cocaine, heroin, 

and alcohol 

59.8 17.1 6.3 

Overall 39.3 11.7 3.7 

Source: Flynn et al. 1996; data are from the NIDA-supported DATOS study. 

disorder–only clients (Coffey et al. 2001). This 

estimate is based on an analysis of the 

CSAT/Center for Mental Health Services 

(CMHS) Integrated Data Base Project, in 

which a team studied information from the 

mental health, substance abuse, and Medicaid 

agencies in Delaware, Oklahoma, and 

Washington. Using a broad coding for health 

policy research to study discharges between 

1990–1995 from community hospitals nationwide, Duffy (2004, p. 45) estimated that clients 

classified as having both a substance-related 

disorder and a mental disorder significantly 

“...increased from 9.4 to 17.22 per 10,000 population ...” with the 35–45 year age group 

increasing the most among the 7 age groups 

studied from childhood to 65 or older. 

Treatment Innovation for 

Other Populations With COD 

Further treatment innovation has been 

required to meet the needs and associated 

problems of other treatment populations with 

high rates of COD such as people who are 

homeless, those in the criminal justice system, 

persons living with HIV/AIDS and other infectious diseases (e.g., hepatitis), and those with 

trauma and posttraumatic stress disorder 

(PTSD). 

Homeless populations 

Data on the increasing rates of co-occurring 

mental and sub stance use disorders in homeless populations are now available (North et 

al. 2004). North and colleagues estimate that 

rates of co-occurring Axis I and substance use 

disorders among females who are homeless 

increased from 14.3 percent in 1990 to 36.7 

8 Introduction 
percent in 2000 and that rates among men 

who are homeless increased from 23.2 percent 

in 1990 to 32.2 percent in 2000. 

North and colleagues also compared data collected in their 2000 study with estimates from 

ECA data collected in the early 1980s. They 

found that alcohol and drug use for both 

males and females rose considerably over the 

2 decades. In 2000, 84 percent of the men 

who were homeless and 58 percent of the 

women who were homeless had a substance 

use disorder (North et al. 2004). The article 

reports an increase in bipolar disorder from 

1990 to 2000 and an increase in major 

depression from 1980 to 2000. (Major depression accounted for the majority of all Axis I 

non-substance disorders.) The authors also 

noted that non-Axis I antisocial personality 

disorder (APD) appeared to change little 

from 1980 to 2000, with 10 to 20 percent of 

women who were homeless and 20 to 25 percent of men who were homeless receiving APD 

diagnoses in both time periods (North et al. 

2004). 

The increased prevalence of COD among people who are homeless and the need to provide 

services to this growing population has led to 

treatment innovations and research on service 

delivery. One of the main challenges is how to 

engage this group in treatment. CMHS’s Access 

to Community Care and Effective Services and 

Supports initiative, which supported programs 

in nine States over a 5-year period, indicated 

the effectiveness of integrated systems, including the value of street outreach (Lam and 

Rosenheck 1999; Rosenheck et al. 1998). Both 

systems integration and comprehensive services, such as Assertive Community Treatment 

(ACT) and Intensive Case Management (ICM), 

were seen as essential and effective (Integrating 

Systems of Care 1999; Winarski and Dubus 

1994). (See chapter 6 for a discussion of these 

approaches.) 

Offenders 

The Bureau of Justice Statistics estimates that 

“at midyear 1998, an estimated 283,800 mentally ill offenders were incarcerated in the 

Nation’s prisons and jails” (Ditton 1999, p. 

1). Surveys by the Bureau found that “16 

percent of State prison inmates, 7 percent of 

Federal inmates, and 16 percent of those in 

local jails reported either a mental condition 

or an overnight stay in a mental hospital” 

(Ditton 1999). In addition, an estimated 

547,800 probationers—16 percent—said they 

had had a mental condition or stayed 

overnight in a mental hospital at some point 

in their lifetime (Ditton 1999). 

The Office of National Drug Control Policy 

(ONDCP) emphasized that “the fastest and 

most cost-effective way to reduce the demand 

for illicit drugs is to treat chronic, hard core 

drug users” (ONDCP 1995, p. 53). These 

“hard core users” are in need of COD services. 

The NTIES study reported that, when given 

the choice to rate their desire for certain services as “not important,” “somewhat important,” or “very important,” 37 percent of a 

population that was predominantly criminaljustice–involved rated mental health services as 

“very important” (Karageorge 2000). 

The substance abuse treatment and mental 

health services communities have been called 

on to provide, or assist in providing, treatment 

to these individuals. This requires the integration of substance abuse treatment and mental 

health services and the combination of these 

approaches with those that address criminal 

thinking and behavior, while attending to both 

public health and public safety concerns. 

HIV/AIDS and infectious 

diseases 

The association between psychological dysfunction and a tendency to engage in highrisk behaviors (Joe et al. 1991; Simpson et al. 

1993) suggests that it is important to integrate 

HIV/AIDS prevention and treatment with 

Introduction 9 
substance abuse treatment and mental health 

services for the COD population. Advances in 

the treatment of HIV/AIDS (such as antiretroviral combination therapy, including 

protease inhibitors) and the improved outcomes resulting from such therapies potentially will extend the survival of those with 

HIV/AIDS and co-occurring disorders. This 

will extend their requirement for continued 

mental health and substance abuse services. 

For persons with COD who also have 

HIV/AIDS or other infectious diseases (e.g., 

hepatitis C), primary medical care should be 

integrated with COD treatment. To be successful, this treatment should include an 

emphasis on treatment adherence (see chapter 7 for one such model). 

Trauma and PTSD 

Many persons with substance use disorders 

have experienced trauma, often as a result of 

abuse. A significant number of them have the 

recognized mental disorder known as PTSD. 

Recent studies have demonstrated strong connections between trauma and addictions, 

including the possibility that childhood abuse 

plays a part in the development of substance 

use disorders (Anderson et al. 2002; Brady et 

al. 2000; Chilcoat and Breslau 1998b; 

Jacobsen et al. 2001). Although substance 

abuse treatment clinicians have counseled 

these clients for years, new treatment strategies for PTSD and trauma have expanded 

treatment options (see chapter 8 and appendix D). The forthcoming TIP Substance 

Abuse Treatment and Trauma will explore 

these issues in depth (CSAT in development d). 

Changes in Treatment 

Delivery 

The substance abuse treatment field has recognized the importance of COD programming. In 1995, only 37 percent of the substance use disorder treatment programs 

reporting data to the Substance Abuse and 

Mental Health Services Administration 

(SAMHSA) offered COD programming. By 

1997, this percentage had increased to almost 

half (data not shown). 

According to 2002 N-SSATS data, the number 

of programs for COD peaked in 1999, followed by a slight decline in 2000 that 

remained constant in 2002. This tracked the 

number of substance use disorder treatment 

providers, which also peaked in 1999. In 

1999, there were 15,239 substance abuse 

treatment programs reporting to SAMHSA; in 

2000, there were 13,428; in 2002, there were 

13,720 (OAS 2003a). Figure 1-3 shows that 

the number of programs for people with COD 

decreased slightly from 1999 to 2000, from 

6,818 to 6,696, but remained constant in 2002 

at 6,696 (OAS 2003a). However, the ratio 

between the total number of substance abuse 

treatment programs and those offering COD 

programming has been relatively stable since 

1997, increasing slightly from 44.7 percent in 

1999 to 49.9 percent in 2000, and then 

remaining roughly constant at 48.8 percent in 

2002. 

An important consideration for the public 

mental health and substance abuse delivery 

systems is the recognition that not all people 

with emotional problems are candidates for 

care within the public mental health system. 

Because many States prioritize the funding of 

mental health slots by providing access to 

those who meet the criteria for the most 

severe and persistent mental illnesses, it is 

important for treatment providers to recognize the criteria that their State jurisdiction 

uses to provide care. For example, a treatment program may be aware that a person 

has psychological symptoms signifying stress, 

a diagnosable mental disorder, a serious mental disorder, a severe and persistent mental 

disorder, or, finally, a severe and persistent 

mental disorder with disability. From the 

point of view of the behavioral healthcare 

delivery system, these distinctions are important. In a State that restricts the use of its 

Federal community mental health services 

dollars to those with severe and persistent 

mental illness, a person not meeting the criteria for that condition may not be eligible for 

mental health services. 

10 Introduction 
Figure 1-3 

Substance Abuse Treatment Facilities Offering Special Programs for 

Clients With COD: 1999–20021 

1

Survey reference dates were October 1 for 1999 and 2000 and March 29, 2002. See appendix C of source for changes in 

the survey base, methods, and instruments that affect analysis of trends over time. 

Source: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, UFDS Survey, 

1996–1999; National Survey of Substance Abuse Treatment Services (N-SSATS), 2000 and 2002. 

http://wwwdasis.samhsa.gov/dasis2/nssats/nssats_2002_q.pdf

If a client/consumer has a primary substance 

abuse problem and a “non-eligible” mental 

disorder—that is, a disorder that cannot by 

regulation or law be treated in a public mental health program—then all providers should 

be aware of this. The difference between ideal 

care and available care is critical to the utility 

of this TIP. Furthermore, during periods of 

financial difficulty, the prospect of additional 

resources being created to address complex 

problems is not likely. Thus, an integrated 

care framework is preferred in this TIP. An 

integrated framework recognizes that quality 

evidence-based individualized care can be 

provided within a behavioral health delivery 

system using existing resources and partnerships. 

Advances in Treatment 

Advances in the treatment of COD, such as 

improved assessments, psychological interventions, psychiatric medications, and new models 

and methods, have greatly increased available 

options for the counselor and the client. 

“No wrong door” policy 

The publication of Changing the Conversation (CSAT 2000a) signaled several fundamental advances in the field. Of particular 

importance is the principle of “no wrong 

door.” This principle has served to alert 

treatment providers that the healthcare delivery system, and each provider within it, has a 

responsibility to address the range of client 

Introduction 11 
needs wherever and whenever a client presents for care. When clients appear at a facility that is not qualified to provide some type 

of needed service, those clients should carefully be guided to appropriate, cooperating 

facilities, with followup by staff to ensure that 

clients receive proper care. The evolution of 

the Changing the Conversation paradigm signals a recognition that recovery is applicable 

to all people in need of substance abuse services: to the client 

with psychiatric 

problems in the

substance abuse 

treatment delivery

system, the client 

with substance 

abuse problems in 

the traditional mental health services 

delivery system, or 

the client with cooccurring behavior 

problems in a traditional physical 

health delivery system. Every “door” 

in the healthcare

delivery system 

should be the 

“right” door. 

Mutual self-help for people



with COD



Based on the Alcoholics Anonymous model, the 

mutual self-help movement has grown to 

encompass a wide variety of addictions. 

Narcotics Anonymous and Cocaine Anonymous 

are two of the largest mutual self-help organizations for chemical addiction; Recoveries 

Anonymous and Schizophrenics Anonymous 

are the best known for mental illness. Though 

these typically are referred to as “self-help” 

groups, this TIP adopts the term “mutual selfhelp” because it is more descriptive of the way 

most participants see these groups—as a means 

of both helping themselves and supporting each 

other in achieving specific personal goals. 

Treatment 

approaches are 

emerging with 

demonstrated 

effectiveness in		

achieving positive 

outcomes for 

clients with COD. 

Mutual self-help programs, which include but 

are not limited to 12-Step groups, apply a 

broad spectrum of personal responsibility and 

peer support principles, usually including 12­

Step methods that prescribe a planned regimen 

of change. In recent years, mutual self-help 

groups that have been adapted to clients with 

COD have become increasingly available. A 

more extensive discussion of these dual recovery mutual self-help programs can be found in 

chapter 7. 

Integrated care as a priority 

for people with severe and 

persistent mental illness 

For those with severe and persistent mental illness, integrated treatment, as originally articulated by Minkoff (1989), emphasized the correspondence between the treatment models for 

mental illness and addiction in a residential setting. The model stressed a parallel view of 

recovery, concomitant treatment of mental illness and substance abuse, application of treatment stages, and the use of strategies from both 

the mental health and substance abuse treatment fields. During the last decade, integrated 

treatment has continued to evolve, and several 

models have been described (Drake and 

Mueser 1996b; Lehman and Dixon 1995; 

Minkoff and Drake 1991; Solomon et al. 1993). 

For the purposes of this TIP, integrated treatment refers more broadly to any mechanism 

by which treatment interventions for COD 

are combined within the context of a primary 

treatment relationship or service setting. 

Integrated treatment is a means of coordinating substance abuse and mental health interventions to treat the whole person more effectively. In a review of mental health centerbased research for clients with serious and 

persistent mental illness, Drake and colleagues (1998b) concluded that comprehensive, integrated treatment, “especially when 

delivered for 18 months or longer, resulted in 

significant reductions of substance abuse and, 

in some cases, in substantial rates of remission, as well as reductions in hospital use 

and/or improvements in other outcomes” (p. 

12 Introduction 
601). Several studies based in substance 

abuse treatment centers addressing a range of 

COD have demonstrated better treatment 

retention and outcome when mental health 

services were integrated onsite (Charney et al. 

2001; McLellan et al. 1993; Saxon and Calsyn 

1995; Weisner et al. 2001). 

An integrated care framework supports the 

provision of some assessment and treatment 

wherever the client enters the treatment system, ensures that arrangements to facilitate 

consultations are in place to respond to client 

issues for which a provider does not have inhouse expertise, and encourages all counselors and programs to develop increased 

competency in treating individuals with COD. 

Several States have received Community 

Action Grants from SAMHSA to develop comprehensive continuous integrated systems of 

care. It is especially important that appropriate substance abuse and mental health services for clients with COD be designed specifically for the substance abuse treatment system—a system that addresses a wide range of 

COD, not mainly those with severe and persistent mental illness. This subject is explored 

in chapter 3, and some approaches to integrated treatment in substance abuse treatment settings are examined in chapter 3 and 

chapter 6. 

Development of effective 

approaches, models, and 

strategies 

Treatment approaches are emerging with 

demonstrated effectiveness in achieving positive outcomes for clients with COD. These 

include a variety of promising treatment 

approaches that provide comprehensive integrated treatment. Successful strategies with 

important implications for clients with COD 

also include interventions based on addiction 

work in contingency management, cognitive– 

behavioral therapy, relapse prevention, and 

motivational interviewing. These strategies 

are discussed in chapter 5. In fact, it is now 

possible to identify “guiding principles” and 

“fundamental elements” for COD treatment 

in COD settings that are common to a variety 

of approaches. These are discussed at length 

in chapter 3 and chapter 6, respectively. 

Specific program models that have proven 

effective for the COD population with serious 

mental illness include ACT and the Modified 

Therapeutic Community. ICM also has 

proven useful in treating clients with COD. 

See chapter 6 for a discussion of these 

models. 

Pharmacological advances 

Pharmacological advances over the past 

decade have produced antipsychotic, antidepressant, anticonvulsant, and other medications with greater effectiveness and fewer side 

effects (see appendix F for a listing of medications). With the support available from better 

medication regimens, many people who once 

would have been too unstable for substance 

abuse treatment, or institutionalized with a 

poor prognosis, have been able to lead more 

functional lives. To meet the needs of this 

population, the substance abuse treatment 

counselor needs both greater understanding 

of the signs and symptoms of mental illness 

and greater capacity for consultation with 

trained mental healthcare providers. As substance abuse treatment counselors learn more 

about mental illness, they are better able to 

partner with mental health counselors to 

design effective treatment for both types of 

disorders. Such partnerships benefit mental 

health agencies as well, helping them enhance 

their ability to treat clients with substance 

abuse issues. 

Increasingly, substance abuse treatment 

counselors and programs have come to appreciate the importance of providing medication 

to control symptoms as an essential part of 

treatment. The counselor has an important 

role in describing client behavior and symptoms to ensure that proper medication is prescribed when needed. The peer community 

also is a powerful tool that can be employed 

to support and monitor medication adherence. Support from mutual self-help groups 

can include learning about the effects of medIntroduction 13 
ication and learning to accept medication as 

part of recovery. Monitoring involves clients 

learning from and reflecting on their own and 

others’ reactions, thoughts, and feelings 

about the ways medications affect them, both 

positively as symptoms are alleviated, and 

negatively as unwanted side effects may 

occur. 

Some Recent Developments 

Since the consensus panel for this TIP was 

convened, there have been several important 

developments in the field of co-occurring disorders. Following is a description of the most 

recent developments in the field. 

National Registry of Effective 

Programs and Practices 

To help its practice and policymaking constituents learn more about evidence-based 

programs, SAMHSA’s Center for Substance 

Abuse Prevention created the National 

Registry of Effective Programs and Practices 

(NREPP), a resource to review and identify 

effective programs derived primarily from 

existing scientific literature, effective programs assessed by other rating processes, 

SAMHSA, and solicitations to the field. When 

co-occurring disorder treatment programs are 

submitted for NREPP consideration, teams of 

scientists review the programs based on four 

criteria: (1) co-occurring disorders programs, 

(2) psychopharmacological programs, (3) 

workplace programs, and (4) general substance abuse prevention and treatment programs. Evaluation is based on methodological 

quality (a program’s overall rigor and substantive contribution) and appropriateness 

(dissemination capability, cultural sensitivity, 

and consumer involvement to inform a total 

rating that describes a program’s readiness 

for adoption and replication). Programs that 

demonstrate a commitment to complete 

assessment and comprehensive services 

receive priority. For programs that target 

persons with serious mental disorders, priority is given to approaches that integrate substance abuse treatment and mental health services. Targeted techniques and strategies are 

also eligible for NREPP review. For more 

detailed information about NREPP, see 

http://nrepp.samhsa.gov/. 

Co-Occurring Disorders State 

Incentive Grants 

The Co-Occurring Disorders State Incentive 

Grants (COSIG) (funded through SAMHSA’s 

CSAT and CMHS) provide funding to the 

States to develop or enhance their infrastructure to increase their capacity to provide 

accessible, effective, comprehensive, coordinated/integrated, and evidence-based treatment services to persons with COD. COSIG 

uses the definition of co-occurring disorders 

from this TIP (see the beginning of this chapter). It supports infrastructure development 

and services across the continuum of COD, 

from least severe to most severe, but the 

emphasis is on people with less severe mental 

disorders and more severe substance use disorders, and on people with more severe mental disorders and less severe substance use 

disorders (i.e., quadrants II and III—see 

chapter 2 for a description of the four quadrants). COSIG is appropriate for States at 

any level of infrastructure development. 

COSIG also provides an opportunity to evaluate the feasibility, validity, and reliability of 

the proposed co-occurring performance measures for the future Performance Partnership 

Grants. Some States and communities 

throughout the country already have initiated 

system-level changes and developed innovative programs that overcome barriers to providing services for individuals of all ages who 

have COD. The COSIG program reflects the 

experience of States to date. For more information, see http://www.samhsa.gov. 

Co-Occurring Center for 

Excellence 

As a result of the pressing need to disseminate 

and support the adoption of evidence- and 

consensus-based practices in the field of 

14 Introduction 
COD, SAMHSA established the Co-Occurring 

Center for Excellence (COCE) in 2003. COCE 

provides SAMHSA and the field with key 

resources needed to disseminate knowledge 

and increase adoption of evidence-based 

practices in the systems and programs that 

serve people with COD. The COCE mission 

is to 

•Transmit advances in substance abuse and 

mental health treatment that address all 

levels of mental disorder severity and that 

can be adapted to the unique needs of each 

client. 

•Guide enhancements in the infrastructure 

and clinical capacities of the substance 

abuse and mental health service systems. 

•Foster the infusion and adoption of evidence-based treatment and program innovation into clinical practice. 

To guide its work, COCE has developed a 

framework that locates the key topics in COD 

along three dimensions: services and service 

systems, infrastructure, and special populations. Services and service systems include 

providers and the services they offer; the 

nature and structure of the organizations and 

systems in which services are delivered; and 

the interrelationships among various providers, 

organizations, and systems. Infrastructure 

includes the wide variety of national, State, 

and local policies, programs, and resources 

that support, facilitate, catalyze, and otherwise 

contribute to the work of service providers and 

service systems. Special populations identifies 

groups who may require special services, settings, or accommodations to reap the full benefit of COD-related services. At this time, the 

core products and services of the COCE are 

envisioned as technical assistance and training, 

a Web site (http://www.samhsa.gov/co-occurring),

meetings and conferences, and future COCE 

products and services. 

As substance abuse

treatment counselors

learn more about

mental illness, they 

can better partner 

with mental health 

counselors to design

effective treatment

for both disorders.

Report to Congress on the 

Prevention and Treatment of 

Co-Occurring Substance Use 

Disorders and Mental 

Disorders 

In response to a Congressional mandate, in 

December 2002 the Department of Health and 

Human Services provided Congress with a 

comprehensive report 

on treatment and prevention of co-occurring substance abuse 

and mental disorders. 

The report emphasizes that people with 

co-occurring disorders 

can and do recover 

with appropriate 

treatment and support 

services. It also finds 

there are many longstanding systemic barriers to appropriate 

treatment and support 

services for people 

with co-occurring disorders, including separate administrative 

structures, eligibility 

criteria, and funding 

streams, as well as 

limited resources for 

both mental health 

services and substance 

abuse treatment. The 

report identifies the need for various Federal 

and State agencies, providers, researchers, 

recovering persons, families, and others to 

work together to create a system in which both 

disorders are addressed as primary and treated 

as such. It also outlines a 5-year blueprint for 

action to improve the opportunity for recovery 

by increasing the availability of quality prevention, diagnosis, and treatment services for people with co-occurring disorders. To access the 

full report, see http://www.samhsa.gov/reports/ 

congress2002/index.html. 

Introduction 15 
Co-Occurring Disorders:
 


Integrated Dual Disorders
 


Treatment Implementation
 


Resource Kit
 


Known simply as the “tool kit,” and developed 

by the Psychiatric Research Center at New 

Hampshire-Dartmouth under the leadership of 

Robert E. Drake, M.D., Ph.D., this resource 

package specifically targets clients with COD 

who have SMI and who are seeking care 

through mental health services available in 

their community. 

The six evidencebased practices

described in the tool 

kit are collaborative 

psychopharmacology, ACT, family psychoeducation, supported employment, 

illness management 

and recovery, and 

integrated dual disorders treatment 

(substance use and

mental illness). 

Using materials germane to a variety of 

audiences (i.e., consumers, family 

members/caregivers,

mental health program leaders, public 

mental health 

authorities, and 

practitioners/clinical 

supervisors), the 

tool kit articulates a 

flexible basic plan 

that allows materials to be used to implement



best practices to their maximum effect. The



tool kit is being produced under a contract



with SAMHSA’s CMHS a nd through a grant



from The Robert Wood Johnson Foundation



(CMHS in development). 
 

The TIP is structured to meet the 

needs of the 

addiction counselor with a basic 

background as 

well as the differing needs of those 

with intermediate 

and advanced 

backgrounds.		

Organization of 

This TIP 

Scope 

The TIP attempts to summarize for the clinician the state-of-the-art in the treatment of 

COD in the substance abuse and mental health 

fields. It contains chapters on terminology, 

assessment, and treatment strategies and models, as well as recommendations for treatment, 

research, and policy planning. 

The primary concern of this TIP is co-occurring substance use (abuse and dependence) 

and mental disorders, even though it is recognized that this same vulnerable population 

also is subject to many other physical and 

social ills. The TIP includes important work 

on nicotine dependence, a somewhat large 

and separate body of work that admittedly 

does need further integration into the general 

field of COD. Nicotine dependency is treated 

here as an important cross-cutting issue. 

Finally, although the TIP does address several specific populations (i.e., homeless, criminal justice, and women), it does this briefly 

and does not describe programs specifically 

for adolescents or for such specialized populations as new Asian and Hispanic/Latino 

immigrants. At the same time, the authors 

fully recognize, and the TIP states, that all 

COD treatment must be culturally relevant. 

Audience 

The primary audience for this TIP is substance 

abuse treatment clinicians and counselors, 

many, but not all, of whom possess certification 

in substance abuse counseling or related professional licensing. Some may have credentials 

in the treatment of mental disorders or in criminal justice services. The TIP is structured to 

meet the needs of the addiction counselor with 

a basic background as well as the differing 

needs of those with intermediate and advanced 

backgrounds. Another equally important audience for the TIP is mental health staff. 

Secondary audiences include educators, 

researchers, primary care providers, criminal 

16 Introduction 
justice staff, and other healthcare and social 

service personnel who work with people with 

COD. 

Approach 

The TIP uses three criteria for inclusion of a 

particular strategy, technique, or model: (1) 

definitive research (i.e., evidence-based treatments), (2) well-articulated approaches with 

empirical support, and (3) consensus panel 

agreement about established clinical practice. 

The information in this TIP derives from a 

variety of sources, including the research literature, conceptual writings, descriptions of 

established program models, accumulated clinical experience and expertise, government 

reports, and other available empirical evidence. It is a document that reflects the current 

state of clinical wisdom in the treatment of 

clients with COD. 

The TIP keeps two questions in the forefront: 

1.		 What does the clinician need to know? 

2.		 How can the information be conveyed in a 

manner that makes it readily accessible? 

Guidance for the Reader 

This TIP is both a resource document and a 

guide on COD that contains both up-to-date 

knowledge and instructive material. It includes 

selected literature reviews, synopses of many 

COD treatment approaches, and some empirical information. The scope of the work in this 

field generated a complex and extensive document that is probably best read by chapter or 

section. It contains text boxes, case histories, 

illustrations, and summaries to synthesize 

knowledge that is grounded in the practical 

realities of clinical cases and real situations. A 

special feature throughout the TIP—”Advice 

to the Counselor”—provides the TIP’s most 

direct and accessible guidance for the counselor. Readers with basic backgrounds, such as 

addiction counselors or other practitioners, 

can study the Advice to the Counselor boxes 

first for the most immediate practical guidance. 

In particular, the Advice to the Counselor 

boxes provide a distillation of what the counselor needs to know and what steps to take, 

which can be followed by a more detailed reading of the relevant material in the section or 

chapter. 

The chair and co-chair of the TIP consensus 

panel plan to continue working with 

providers and treatment agencies, and 

encouraging others to do likewise, to translate 

the concepts and methods of the TIP into 

other useable tools specifically shaped to the 

needs and resources of each agency and situation. It is the hope of the consensus panel that 

the reader will come away with increased 

knowledge, encouragement, and resources for 

the important work of treating persons with 

COD. 

Organization 

The TIP is organized into 9 chapters and 14 

appendices. Subject areas addressed in each of 

the remaining chapters and appendices are as 

follows: 

Chapter 2. Definitions, terms, 

and classification systems for 

co-occurring disorders 

This chapter reviews terminology and classifications related to substance use, clients, treatment, programs, and systems for clients with 

COD. Key terms used in the TIP and in the 

field are defined to help the reader understand 

the framework and language used in this TIP 

and how this language relates to other terminology and classifications that are familiar to 

the reader. The main classification systems currently in use in the field are presented. 

Chapter 3. Keys to successful 

programming 

The chapter begins with a review of some guiding principles in treatment of clients with COD, 

and key challenges to establishing services in 

substance abuse treatment settings are highlighted. This section also presents a system for 

Introduction 17 
classifying substance abuse treatment programs 

to determine an appropriate level of services 

and care. The chapter describes some service 

delivery issues including access, assessment, 

integrated treatment, comprehensive services, 

and continuity of care. Finally, critical issues in 

workforce development are discussed, including values, competencies, education, and training. 

Chapter 4. Assessment 

This chapter reviews the key principles of 

assessment, selected assessment instruments, 

and the assessment process. The chapter also 

addresses the specific relationship of assessment to treatment planning. 

Chapter 5. Strategies for 

working with clients with 

co-occurring disorders 

This chapter presents guidelines for developing 

a successful therapeutic relationship with individuals who have COD. It describes specific 

techniques for counselors that appear to be the 

most successful in treating clients with COD 

and introduces guidelines that are important 

for the successful use of all these strategies. 

Chapter 6. Traditional 

settings and models 

The chapter begins by addressing essential programming for clients with COD that can readily 

be offered in most substance abuse treatment 

settings. Overarching considerations in effective treatment for this population, regardless of 

setting, are reviewed. Practices are highlighted 

that have proven effective for the treatment of 

persons with COD in outpatient and residential 

settings. The chapter also highlights several distinctive models. 

Chapter 7. Special settings 

and specific populations 

This chapter addresses issues related to providing treatment to clients with COD in acute care 

and other medical settings, as well as the need 

to sustain these programs. Because of the critical role mutual self-help groups play in recovery, several dual recovery mutual self-help 

groups that address the specific concerns of 

clients with COD are described. Resources 

available through advocacy groups are highlighted. Finally, the chapter discusses the need 

to address the particular needs of people with 

COD within three key populations: homeless 

persons, criminal justice populations, and 

women. 

Chapter 8. A brief overview 

of specific mental disorders 

and cross-cutting issues 

With the permission of American Psychiatric 

Publishing, Inc. (APPI), the consensus panel 

has taken the opportunity to present to the 

substance abuse treatment audience basic 

information contained in the Diagnostic and 

Statistical Manual for Mental Disorders, 4th 

edition, Text Revised (DSM-IV-TR). The 

chapter updates material that was presented 

on the major disorders covered in TIP 9 (i.e., 

personality disorders, mood disorders, anxiety disorders, and psychotic disorders) and 

adds other mental disorders with particular 

relevance to COD that were not covered in 

TIP 9 (i.e., attention deficit/hyperactivity disorder, PTSD, eating disorders, and pathological gambling). Suicidality and nicotine 

dependency are presented as cross-cutting 

issues. The consensus panel is pleased that 

APPI has allowed this liberal use of its materials to help foster the co-occurring disorders 

field and positive interchange between the 

substance abuse treatment and mental health 

services fields. 

The chapter contains key information about 

substance abuse and the particular mental 

disorder, highlighting advice to the counselor 

to help in working with clients with those disorders. A relevant case history accompanies 

each disorder in this chapter. This chapter is 

meant to function as a “quick reference” to 

help the substance abuse treatment counselor 

understand the mental disorder diagnosis and 

18 Introduction 
its implications for treatment planning. 

Appendix D contains a more extensive discussion of the same disorders. 

Chapter 9. Substance-induced 

disorders 

This chapter provides information on mental 

disorder symptoms caused by the use of substances. It outlines the toxic effect of substances and provides an overview of substanceinduced symptoms that can mimic mental disorders. 

Appendices 

Appendix A. Bibliography 

Appendix A contains the references cited in 

this TIP and other resources used for background purposes but not specifically cited. 

Appendix B. Acronyms 

Appendix B contains a key to all the acronyms 

used in this TIP. 

Appendix C. Glossary of terms 

This appendix contains the definitions of terms 

used in this TIP, with the exception of terminology related to specific mental disorders discussed in chapter 8 and appendix D. For these 

specialized terms, the reader is advised to consult a medical dictionary. 

Appendix D. Specific mental disorders: Additional guidance for the 

counselor 

Clients with COD entering treatment often have 

several disorders, each of which is associated 

with a growing body of knowledge and range of 

treatment options. This appendix is meant to 

serve substance abuse treatment counselors 

and programs as a resource and training document that provides more extensive information 

on individual mental disorders than could be 

included in chapter 8. Although most readers 

will not read the entire appendix at one time, 

this mental disorder-oriented section is included so that a counselor who is working with a 

new client with one or more of these disorders 

can have detailed information readily available. 

Appendix E. Emerging models 

In this appendix, the reader can find descriptions of several recent models of care for persons with COD that were (or are being) evaluated under initiatives funded by SAMHSA’s 

CSAT. Though selective and based primarily 

on available information from recent SAMHSA 

initiatives, it is hoped that these models will 

suggest ways in which readers working with a 

variety of client types and symptom severities 

in different settings can improve their capacities to assess and treat these clients. 

Appendix F. Common medications 

for disorders 

Because medication is such an important 

adjunct to treatment, this appendix offers a 

brief review of key issues in pharmacologic 

management. A table of common medications 

for various disorders follows this discussion, 

with comments on the effects of these medications and their implications for addiction 

counselors and treatment. This material is 

taken from the Pharmacological Management 

section of TIP 9 (CSAT 1994a, pp. 91–94), 

followed by the complete text of Psychotherapeutic Medications 2004: What Every 

Counselor Should Know (Mid-America 

Addiction Technology Transfer Center 2004). 

Appendix G. Screening and assessment instruments 

A list of selected screening and assessment tools 

referenced in chapter 4, along with key information on the use of each instrument, appears 

in this appendix. As a full review of these 

instruments was beyond the scope of this TIP, 

readers are urged to review the literature to 

determine their reliability, validity, and utility, 

and to gain an understanding of their applicability to specific situations. 

Introduction 19 
Appendix H. Sample screening 

instruments 

This appendix offers two screening instruments 

available for unrestricted use: 

•

•

The Mental Health Screening Form-III 

The Simple Screening Instrument for 

Substance Abuse 

Appendix I. Selected resources of 

training 

Here the reader finds some of the most readily 

available and well-used sources of training in 

substance abuse treatment, mental health services, and co-occurring disorders. 

Appendix J. Dual recovery mutual 

self-help programs and other 

resources for consumers and 

providers 

This appendix provides a brief description and

contact information for several mutual selfhelp groups discussed in the TIP. 

Appendix K. Confidentiality

This appendix provides a brief description of

the Federal Alcohol and Drug Confidentiality

Law and Regulations (42 C.F.R. Part 2) and 

the Health Insurance Portability and

Accountability Act of 1996.

1

“These estimates are from the National Comorbidity Survey. The survey was based on interviews administered to a 

probability sample of the noninstitutionalized U.S. civilian population. The NCS sample consisted of 8,098 respondents, 

age 15 to 54 years. This survey was conducted from September 1990 to February 1992. DSM-III-R criteria were used as 

the basis for assessing disorders in the general population. A random sample of initial nonrespondents was contacted 

further and received a financial incentive to participate. A nonresponse weight was used to adjust for the higher rates of 

[alcohol, drugs, or mental (ADM) disorders] found in the sample of initial nonresponders. The Composite International 

Diagnostic Interview was modified to eliminate rare diagnoses in the age group studied and to add probes to improve 

understanding and motivation. The ‘substance abuse/dependence’ category includes drugs and alcohol. ‘Any ADM disorder’ includes the following: affective, anxiety, substance abuse/dependence, nonaffective psychosis, and antisocial personality disorders. ‘Affective disorders’ include major depressive episode, manic episode, and dysthymia. Anxiety disorders include panic disorder, agoraphobia, social phobia, simple phobia, and generalized anxiety disorder. Antisocial 

personality was assessed only on a lifetime basis. Nonaffective psychoses include schizophrenias, delusional disorder, 

and atypical psychoses. Substance abuse/dependence includes both abuse of and dependence on alcohol and other 

drugs” (SAMHSA 1998, p. 7). 

20 Introduction 
2 Definitions, Terms, 

and Classification 

Systems for CoOccurring Disorders 

In This 

Chapter... 

Terms Related to
 


Substance Use



Disorders 
 

Terms Related to
 


Mental Disorders



Terms Related 
 

to Clients



Terms Related 
 

to Treatment
 


Terms Related 
 

to Programs



Terms Related 
 

to Systems



Overview 

This chapter reviews and defines many of the terms that are applied 

commonly to co-occurring substance use and mental disorders (COD). 

Discussion points include how different terms have emerged, the contexts in which various classification systems are likely to be used, and 

why many of the specific terms and classification systems used throughout this TIP were chosen. 

After a review of basic terminology related to substance use (including 

the distinction between abuse and dependence) and a brief description of 

mental disorders, the chapter discusses terms related to clients. A key 

point is the importance of using person-centered terminology as a way of 

acknowledging each client’s individuality. The chapter notes the many 

terms that may be used to describe co-occurring disorders, reviews the 

terms related to treatment and programs, and concludes with an 

overview of terms that describe the systems of care within which treatment occurs and programs operate. 

The addiction counselor should be aware that the terminology and 

classifications introduced in this chapter, though important and useful, were developed by different groups for different purposes. 

Therefore, these terms do not necessarily form a seamless picture or 

work smoothly together. Nevertheless, they are useful and appropriate when used in the intended context. The reader who becomes conversant with these terms and classifications will find it easier to navigate the discussion of treatment issues (chapter 3) and to follow the 

TIP’s narrative. 

Finally, this chapter contains brief Advice to the Counselor boxes, 

which readers with basic backgrounds, such as addiction counselors 

or other practitioners, can refer to for the most immediate practical 

guidance. (For a full listing of these boxes see the table of contents.) 

21 
Terms Related to 

Substance Use 

Disorders 

Substance abuse and substance dependence 

are two types of substance use disorders and 

have distinct meanings. The standard use of 

these terms derives from the Diagnostic and 

Statistical Manual of Mental Disorders, 4th 

edition (DSM-IV) (American Psychiatric 

Association [APA] 1994). Produced by the 

APA and updated periodically, DSM-IV is 

used by the medical and mental health fields 

for diagnosing mental and substance use disorders. This reference provides clinicians 

with a common language for communicating 

about these disorders. The reference also 

establishes criteria for diagnosing specific disorders. 

Substance abuse, as defined in DSM-IV-TR 

(4th edition, Text Revision; APA 2000), is a 

“maladaptive pattern of substance use manifested by recurrent and significant adverse 

consequences related to the repeated use of 

substances” (APA 2000, p. 198). Individuals 

who abuse substances may experience such 

harmful consequences of substance use as 

repeated failure to fulfill roles for which they 

are responsible, legal difficulties, or social 

and interpersonal problems. It is important 

to note that the chronic use of an illicit drug 

still constitutes a significant issue for treatment even when it does not meet the criteria 

for substance abuse specified in the text box 

below. 

For individuals with more severe or disabling 

mental disorders, as well as for those with 

developmental disabilities and traumatic 

brain injuries, even the threshold of substance use that might be harmful (and therefore defined as abuse) may be significantly 

lower than for individuals without such disorders. Further-more, the more severe the disability, the lower the amount of substance use 

that might be harmful. 

Substance dependence is more serious than 

abuse. This maladaptive pattern of substance 

use includes such features as increased tolerance for the substance, resulting in the need 

for ever-greater amounts of the substance to 

achieve the intended effect; an obsession with 

securing the substance and with its use; or 

persistence in using the substance in the face 

of serious physical or mental health problems. See the text box on page 23 for more 

information. 

Criteria for a Diagnosis of Substance Abuse 

A. 	 A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: 

1.		 Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home 

(e.g., repeated absences or poor work performance related to substance use; substance-related 

absences, suspensions, or expulsions from school; neglect of children or household) 

2.		 Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or 

operating a machine when impaired by substance use) 

3.		 Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct) 

4.		 Continued substance use despite having persistent or recurrent social or interpersonal problems caused 

by or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of 

intoxication, physical fights) 

B. 	 The symptoms have never met the criteria for Substance Dependence for this class of substance. 

Source: APA 2000, p. 199. 

22 Definitions, Terms, and Classification Systems for Co-Occurring Disorders 
Criteria for a Diagnosis of Substance Dependence 

A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 

three (or more) of the following, occurring at any time in the same 12-month period: 

1. 	 Tolerance, as defined by either of the following: 

a.		 A need for markedly increased amounts of the substance to achieve intoxication or desired effect. 

b.		 Markedly diminished effect with continued use of the same amount of the substance. 

2. 	 Withdrawal, as manifested by either of the following: 

a.		 The characteristic withdrawal syndrome for the substance (refer to the DSM-IV-TR, Criteria A and B of 

the criteria sets for withdrawal from the specific substances). 

b.		 The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. 

3. 	 The substance is often taken in larger amounts or over a longer period than was intended. 

4. 	 There is a persistent desire or unsuccessful efforts to cut down or control substance use. 

5. 	 A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors 

or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects. 

6. 	 Important social, occupational, or recreational activities are given up or reduced because of substance 

use. 

7. 	 The substance use is continued despite knowledge of having a persistent or recurrent physical or mental 

health problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine 

use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an 

ulcer was made worse by alcohol consumption). 

Source: APA 2000, p. 197. 

The term substance abuse has come to be 

used informally to refer to both abuse and 

dependence. Substance abuse treatment professionals commonly use the term “substance 

abuse” to describe any excessive use of addictive substances, whether the substance is 

alcohol or another drug. By and large the 

terms “substance dependence” and “addiction” have come to mean the same thing, 

though there is debate about the interchangeable use of these terms. When only those who 

are diagnosed as dependent are referenced, 

the specific term will be used. 

Terms Related to 

Mental Disorders 

The standard use of terms for non-substance 

use mental disorders, like the terms for substance use disorders, derive from the DSM-IVTR (APA 2000). These terms are used throughout the medical and mental health fields for 

diagnosing mental disorders. As with substance 

use disorders, this reference provides clinicians 

with a common language for communicating 

about these disorders. The reference also 

establishes criteria for diagnosing specific disorders. (See chapter 1, Figure 1-2 for an 

overview of the association between specific 

mental disorders and substance use disorders.) 

Definitions, Terms, and Classification Systems for Co-Occurring Disorders 23 
The following section provides a brief introduction to some (not, by any means, all) of these 

disorders and offers advice to the addiction 

counselor and other practitioners for working 

with clients with these disorders. The consensus panel recognizes that addiction counselors 

are not expected to diagnose mental disorders. 

Clinicians in the substance abuse treatment 

field, however, should familiarize themselves 

with the mental disorders that co-occur with 

substance use disorders and/or that mimic 

symptoms of substance use disorders, particularly withdrawal or intoxication. The aim of 

providing this material is only to increase substance abuse treatment counselors’ familiarity 

with the mental disorders terminology and criteria necessary to provide advice on how to 

proceed with clients who demonstrate these disorders. (See chapter 8 and appendix D for 

more complete material on mental disorders cooccurring with substance use disorders.) 

Personality Disorders 

These are the disorders most commonly seen by 

the addiction counselor and in quadrant III 

substance abuse treatment settings (see Figure 

2-1 for a depiction of the four quadrants). 

Individuals with personality disorders have 

symptoms and personality traits that are 

enduring and play a major role in most, if not 

all, aspects of the person’s life. These individuals have personality traits that are persistent 

and cause impairment in social or occupational 

functioning or cause personal distress. 

Symptoms are evident in their thoughts (ways 

of looking at the world, thinking about self or 

others), emotions (appropriateness, intensity, 

and range), interpersonal functioning (relationships and interpersonal skills), and impulse 

control. 

Personality disorders are listed in the DSMIV under three distinct areas, referred to as 

“clusters.” The clusters are listed below with 

the types of symptoms or traits seen in that 

category. The specific personality disorders 

included in each cluster also are listed. For 

personality disorders that do not fit any of 

the specific disorders, the diagnosis of “personality disorder not otherwise specified” is 

used. 

Cluster A: Hallmark traits of this cluster 

involve odd or eccentric behavior. It includes 

paranoid, schizoid, and schizotypal personality disorders. 

Cluster B: Hallmark traits of this cluster 

involve dramatic, emotional, or erratic 

behavior. It includes antisocial, borderline, 

histrionic, and narcissistic personality disorders. 

Cluster C: Hallmark traits of this cluster 

involve anxious, fearful behavior. It includes 

avoidant, dependent, and obsessive-compulsive personality disorders. 

The prevalence of co-occurring substance 

abuse and antisocial personality disorder is 

high (Flynn et al. 1997). In fact, much of substance abuse treatment is targeted to those 

with antisocial personality disorders and substance abuse treatment alone has been especially effective for these disorders. Below is 

an Advice to the Counselor box on working 

with clients who have antisocial personality 

disorder; similar and more 

detailed advice boxes can

be found throughout the

TIP. 

Psychotic

Disorders 

The common characteristics

of these disorders are symptoms that center on probAdvice to the Counselor: 

Antisocial Personality Disorders 

• Confront dishonesty and antisocial behavior directly and 

firmly. 

• Hold clients responsible for the behavior and its consequences. 

• Use peer communities to confront behavior and foster 

change. 

24 Definitions, Terms, and Classification Systems for Co-Occurring Disorders 
lems of thinking. The most prominent (and problematic) symptoms



are delusions or hallucinations. 

Delusions are false beliefs that sig­


nificantly hinder a person’s ability to function. For example, a 

client may believe that people are 

trying to hurt him, or he may 

believe he is someone else (a CIA 

agent, God, etc.). Hallucinations 

are false perceptions in which a 

person sees, hears, feels, or smells 

things that aren’t real (i.e., visual, auditory, tactile, or olfactory). 

Advice to the Counselor:

Psychotic Disorders 

• Screen for psychotic disorders and refer identified clients

for further diagnostic evaluation.

• Obtain a working knowledge of the signs and symptoms

of the disorder. 

• Educate the client and family about the condition. 

• Help the client detect early signs of its re-occurrence by

recognizing the symptoms associated with the disorder. 

Psychotic disorders are seen most frequently 

in mental health settings and, when combined 

with substance use disorders, the substance 

disorder tends to be severe. Clients with psychotic disorders constitute what commonly is 

referred to as the serious and persistent mentally ill population. Increasingly, individuals 

with serious mental illness are present in substance abuse treatment programs (Gustafson 

et al. 1999). 

Drugs (e.g., cocaine, methamphetamine, or 

phencyclidine) can produce delusions and/or



hallucinations secondary to drug intoxication.
 

Furthermore, psychotic-like symptoms may 

persist beyond the acute intoxication period.



Schizophrenia 

This is one of the most common of the psychotic disorders and one of the most destructive in terms of the effect it has on a person’s 

life. Symptoms may include the following: hallucinations, delusions, disorganized speech, 

grossly disorganized or catatonic behavior, 

social withdrawal, lack of interest, and poor 

hygiene. The disorder has several specific types 

depending on what other symptoms the person 

experiences. In the paranoid type there is a 

preoccupation with one or more delusions or 

frequent auditory hallucinations. These often 

are experienced as threatening to the person. 

In the disorganized type there is a prominence 

of all of the following: disorganized speech, disorganized behavior, and flat or inappropriate 

affect (i.e., emotional expression).

Mood Disorders 

The disorders in this category include those 

where the primary symptom is a disturbance in 

mood, where there may be inappropriate, exaggerated, or a limited range of feelings or emotions. Everyone feels “down” sometimes, and

everybody experiences feelings of excitement or 

emotional pleasure. However, when a 

client has a mood disorder, these feelings 

or emotions are experienced to the 

extreme. Many people with substance use

disorders also have a co-occurring mood 

disorder and tend to use a variety of 

drugs in association with their mood disorder. There are several types of mood 

disorders, including depression, mania,

and bipolar disorder. 

Depression. Instead of just feeling

“down,” the client might not be able to 

work or function at home, might feel 

Advice to the Counselor: 

Mood and Anxiety Disorders 

• Differentiate between mood disorders, common-	 

place expressions of depression, and depression associated with more serious mental illness. 

• Conduct careful and continuous assessment since 

mood symptoms may be the result of substance



abuse and not an underlying mental disorder.
 


• Combine addiction counseling with medication and		

mental health treatment. 

Definitions, Terms, and Classification Systems for Co-Occurring Disorders 25 
suicidal, lose his or her appetite, and feel 

very tired or fatigued. Other symptoms can 

include loss of interest, weight changes, 

changes in sleep and appetite, feelings of 

worthlessness, loss of concentration, and 

recurrent thoughts of death. 

Mania. This includes feelings that are toward 

the opposite extreme of depression. There 

might be an excess of energy where sleep is 

not needed for days at a time. The client may 

be feeling “on top of the world,” and during 

this time, the client’s decisionmaking process 

might be significantly impaired and expansive 

and he may experience irritability and have 

aggressive outbursts, although he might think 

such outbursts are perfectly rational. 

Bipolar. A person with bipolar disorder 

cycles between episodes of mania and depression. These episodes are characterized by a 

distinct period of abnormally elevated, 

expansive, or irritable mood. Symptoms may 

include inflated self-esteem or grandiosity, 

decreased need for sleep, being more 

talkative than usual, flight of ideas or a feeling that one’s thoughts are racing, distractibility, increase in goal-directed activity, 

excessive involvement in pleasurable activities 

that have a high potential for painful consequences (sexual indiscretions, buying sprees, 

etc.). Excessive use of alcohol is common during periods of mania. 

Anxiety disorders. As with mood disorders, 

anxiety is something that everyone feels now 

and then, but anxiety disorders exist when 

anxiety symptoms reach the point of frequency and intensity that they cause significant 

impairment. In addiction treatment populations, the most common anxiety syndrome 

seen is that associated with early recovery, 

which can be a mix of substance withdrawal 

and learning to live without the use of drugs 

or alcohol. This improves with time and 

addiction treatment. However, other anxiety 

disorders that may occur, but need particular 

assessment and treatment, are social phobia 

(fear of appearing or speaking in front of 

groups), panic disorder (recurrent panic 

attacks that usually last a few hours, cause 

great fear, and make it hard to breathe), and 

posttraumatic stress disorders (which cause 

recurrent nightmares, anxiety, depression, 

and the experience of reliving the traumatic 

issues). 

Terms Related to 

Clients 

Person-Centered Terminology 

In recent years, consumer advocacy groups 

have expressed concerns related to how clients 

are classified. Many take exception to terminology that seems to put them in a “box” with a 

label that follows them through life, that does 

not capture the fullness of their identities. A 

person with COD also may be a mother, a 

plumber, a pianist, a student, or a person with 

diabetes, to cite just a few examples. Referring 

to an individual as a person who has a specific 

disorder—a person with depression rather 

than “a depressive,” a person with schizophrenia rather than “a schizophrenic,” or a person 

who uses heroin rather than “an addict”—is 

more acceptable to many clients because it 

implies that they have many characteristics 

besides a stigmatized illness, and therefore that 

they are not defined by this illness. 

Terms for Co-Occurring 

Disorders 

Many terms have been used in the field to 

describe the group of individuals who have 

COD (most of these terms do not reflect the 

“people-first” approach used in this TIP). 

Some of these terms represent an attempt to 

identify which problem or disorder is seen as 

primary or more severe. Others have developed in the literature in order to argue for setting aside funding for special services or to 

identify a group of clients who may benefit 

from certain interventions. These terms include 

26 Definitions, Terms, and Classification Systems for Co-Occurring Disorders 
•MICA—mentally ill chemical abuser. This 

acronym is sometimes seen with two As 

(MICAA) to signify mentally ill chemically 

addicted or affected. There are regional differences in the meaning of this acronym. 

Many States use it to refer specifically to persons with serious mental disorders. 

•MISA—mentally ill substance abuser. 

•MISU—mentally ill substance using. 

•CAMI—chemically abusing mentally ill, or 

chemically addicted and mentally ill. 

•SAMI—substance abusing mentally ill. 

•MICD—mentally ill chemically dependent. 

•Dually diagnosed. 

•Dually disordered. 

•Comorbid disorders. 

•ICOPSD—individuals with co-occurring psychiatric and substance disorders. 

While all of these terms have their uses, many 

have developed connotations that are not helpful or that have become too broad or varied in 

interpretation to be useful. For example, “dual 

diagnosis” also can mean having both mental 

and developmental disorders. Readers who 

hear these terms should not assume they all 

have the same meaning as COD and should 

seek to clarify the client characteristics associated with a particular term. Readers also 

should realize that the term “co-occurring disorder” is not inherently precise and distinctive; 

it also may become distorted by popular use, 

with other conditions becoming included within 

the term. The issue here is that clients/consumers may have a number of health conditions that “co-occur,” including physical health 

problems. Nevertheless, for the purpose of this 

TIP, co-occurring disorders refers to substance 

use disorders and mental disorders. 

Some clients’ mental health problems may not 

fully meet the strict definition of co-occurring 

substance use and mental disorders criteria 

for diagnoses in DSM-IV categories. However, 

many of the relevant principles that apply to 

the treatment of COD also will apply to these 

individuals. Careful assessment and treatment planning to take each disorder into 

account will still be important. Suicidal 

ideation is an excellent example of a mental 

health symptom that creates a severity problem, but alone doesn’t necessarily meet criteria for a formal DSM-IV condition since suicidality is a symptom and not a diagnosis. 

Substance-induced suicidal ideation can produce catastrophic consequences. Some individuals may exhibit symptoms that could indicate the existence of COD but could also be 

transitory; for example, substance-induced 

mood swings, which can mimic bipolar disorder, or amphetamine-induced hallucinations 

or paranoia, which could mimic schizophrenia. Depending on the severity of their symptoms, these individuals also may require the 

full range of services needed by those who 

meet the strict criterion of having both conditions independently, but generally for acute 

periods until the substance-induced symptoms resolve. 

Terms Related to 

Treatment 

Levels of Service 

The American Society of Addiction Medicine’s 

Patient Placement Criteria (ASAM PPC-2R) 

(ASAM 2001) envisions treatment as a continuum within which there are five levels of care. 

These levels of care are as follows: 

• Level 0.5:	 	Early Intervention 

• Level I:	 	 Outpatient Treatment 

• Level II:	 	 Intensive Outpatient/Partial 

Hospitalization Treatment 

• Level III: 	 Residential/Inpatient Treatment 

• Level IV: 	 Medically Managed Intensive 

Inpatient Treatment 

Each level of care includes several levels of 

intensity indicated by a decimal point. For 

example, Level III.1 refers to “Clinically 

Managed Low-Intensity Residential 

Definitions, Terms, and Classification Systems for Co-Occurring Disorders 27 
Treatment.” A client who has COD might be 

appropriately placed in any of these levels of 

service. 

Substance abuse counselors also should be 

aware that some mental health professionals 

may use another system, the Level of Care 

Utilization System for Psychiatric and 

Addiction Services. This system also identifies 

levels of care, including 

• Level 1: 	 Recovery Maintenance Health 

Management 

• Level 2: 	 Low Intensity Community Based 

Services 

• Level 3: 	 High Intensity Community Based 

Services 

• Level 4: 	 Medically Monitored NonResidential Services 

• Level 5: 	 Medically Monitored Residential 

Services 

• Level 6: 	 Medically Managed Residential 

Services 

These levels, like the ASAM levels, use a variety of specific dimensions to describe a client in 

order to determine the most appropriate placement (see the section in chapter 4, “Assessment 

Step 5,” for more information about these 

dimensions). 

Quadrants of Care 

The quadrants of care are a conceptual framework that classifies clients in four basic groups 

based on relative symptom severity, not 

diagnosis. 

• Category I: 	 Less severe mental disorder/ 

less severe substance disorder 

• Category II: 	 More severe mental disorder/ 

less severe substance disorder 

• Category III: Less severe mental disorder/ 

more severe substance 

disorder 

• Category IV: 	 More severe mental disorder/ 

more severe substance disorder (National Association of 

State Mental Health Program 

Directors [NASMHPD] and 

National Association of State 

Alcohol and Drug Abuse 

Directors [NASADAD] 1999) 

For a more detailed description of each quadrant, see Figure 2-1 and text box on p. 30. 

The quadrants of care were derived from a 

conference, the National Dialogue on CoOccurring Mental Health and Substance 

Abuse Disorders, which was supported by the 

Substance Abuse and Mental Health Services 

Administration (SAMHSA) and two of its centers—the Center for Substance Abuse 

Treatment (CSAT) and the Center for Mental 

Health Services—and co-sponsored by 

NASMHPD and NASADAD. The quadrants 

of care is a model originally developed by 

Ries (1993) and used by the State of New 

York (NASMHPD and NASADAD 1999; see 

also Rosenthal 1992). 

The four-quadrant model has two distinct 

uses: 

• To help conceptualize an individual client’s 

treatment and to guide improvements in system integration (for example, if the client has 

acute psychosis and is known to the treatment staff to have a history of alcohol dependence, the client will clearly fall into 

Category IV—that is, severe mental disorder 

and severe substance use disorder). However, 

the severity of the client’s needs, diagnosis, 

symptoms, and impairments all determine 

level of care placement. 

• To guide improvements in systems integration, including efficient allocation of 

resources. The NASMHPD–NASADAD 

National Dialogue recognized that currently 

“there is no single locus of responsibility for 

people with COD. The mental health and 

substance abuse treatment systems operate 

independently of one another, as separate 

cultures, each with its own treatment philosophies, administrative structures, and funding 

mechanisms. This lack of coordination means 

that neither consumers nor providers move 

easily among service settings” (NASMHPD 

and NASADAD 1999, p. ii). 

28 Definitions, Terms, and Classification Systems for Co-Occurring Disorders 
Figure 2-1 

Level of Care Quadrants 

low 

severity Alcohol and Other Drug Abuse 

high 

severity Category III 

Mental disorders less severe 

Substance abuse disorders 

more severe Locus of care 

Substance Abuse System 

Category IV 

Mental disorders more severe 

Substance abuse disorders 

more severe Locus of care 

State hospitals, jails/prisons, 

emergency rooms, etc. 

Category I 

Mental disorders less severe 

Substance abuse disorders 

less severe Locus of care 

Primary health care settings 

Category II 

Mental disorders more severe 

Substance abuse disorders less 

severe Locus of care 

Mental health system 

high 

severity 

Mental Illness 

Although the chapters of this TIP are not organized around the four-quadrant framework, 

most of the material in chapters 3 through 7 is 

directed primarily to addiction counselors 

working in quadrant III settings and other 

practitioners working in quadrant II settings. 

Interventions 

Intervention refers to the specific treatment 

strategies, therapies, or techniques that are 

used to treat one or more disorders. 

Interventions may include psychopharmacology, individual or group counseling, cognitive–behavioral therapy, motivational 

enhancement, family interventions, 12-Step 

recovery meetings, case management, skills 

training, or other strategies. Both substance 

use and mental disorder interventions are 

targeted to the management or resolution of 

acute symptoms, ongoing treatment, relapse 

prevention, or rehabilitation of a disability 

associated with one or more disorders, 

whether that disorder is mental or associated 

with substance use. 

Integrated Interventions 

Integrated interventions are specific treatment strategies or therapeutic techniques in 

which interventions for both disorders are 

combined in a single session or interaction, or 

in a series of interactions or multiple sessions. 

Integrated interventions can include a wide 

range of techniques. Some examples include 

• Integrated screening and assessment 

processes 

• Dual recovery mutual self-help meetings 

• Dual recovery groups (in which recovery 

skills for both disorders are discussed) 

• Motivational enhancement interventions 

(individual or group) that address issues 

related to both mental health and substance 

abuse or dependence problems 

Definitions, Terms, and Classification Systems for Co-Occurring Disorders 29 
Level of Care Quadrants 

Quadrant I: This quadrant includes individuals with low severity substance abuse and low severity 

mental disorders. These low severity individuals can be accommodated in intermediate outpatient settings of either mental health or chemical dependency programs, with consultation or collaboration 

between settings if needed. Alternatively, some individuals will be identified and managed in primary 

care settings with consultation from mental health and/or substance abuse treatment providers. 

Quadrant II: This quadrant includes individuals with high severity mental disorders who are usually 

identified as priority clients within the mental health system and who also have low severity substance 

use disorders (e.g., substance dependence in remission or partial remission). These individuals ordinarily receive continuing care in the mental health system and are likely to be well served in a variety 

of intermediate level mental health programs using integrated case management. 

Quadrant III: This quadrant includes individuals who have severe substance use disorders and low or 

moderate severity mental disorders. They are generally well accommodated in intermediate level substance abuse treatment programs. In some cases there is a need for coordination and collaboration 

with affiliated mental health programs to provide ongoing treatment of the mental disorders. 

Quadrant IV: Quadrant IV is divided into two subgroups. One subgroup includes individuals with serious and persistent mental illness (SPMI) who also have severe and unstable substance use disorders. 

The other subgroup includes individuals with severe and unstable substance use disorders and severe 

and unstable behavioral health problems (e.g., violence, suicidality) who do not (yet) meet criteria for 

SPMI. These individuals require intensive, comprehensive, and integrated services for both their substance use and mental disorders. The locus of treatment can be specialized residential substance abuse 

treatment programs such as modified therapeutic communities in State hospitals, jails, or even in settings that provide acute care such as emergency rooms (see chapter 7 for an example in an emergency 

room setting). 

•Group interventions for persons with the 

triple diagnosis of mental disorder, substance 

use disorder, and trauma, or which are 

designed to meet the needs of persons with 

COD and another shared problem such as 

homelessness or criminality 

•Combined psychopharmacological interventions, in which an individual receives medication designed to reduce cravings for substances as well as medication for a mental 

disorder 

Integrated interventions can be part of a single 

program or can be used in multiple program 

settings. 

Episodes of Treatment 

An individual with COD may participate in 

recurrent episodes of treatment involving acute 

stabilization (e.g., crisis intervention, detoxification, psychiatric hospitalization) and specific 

ongoing treatment (e.g., mental-health–supported housing, mental-health day treatment, 

or substance abuse residential treatment). It is 

important to recognize the reality that clients 

engage in a series of treatment episodes, since 

many individuals with COD progress gradually 

through repeated involvement in treatment. 

Integrated Treatment 

Integrated treatment refers broadly to any 

mechanism by which treatment interventions 

for COD are combined within the context of a 

30 Definitions, Terms, and Classification Systems for Co-Occurring Disorders 
primary treatment relationship or service setting. Integrated treatment is a means of 

actively combining interventions intended to 

address substance use and mental disorders 

in order to treat both disorders, related problems, and the whole person more effectively. 

Culturally Competent 

Treatment 

One definition of cultural competence refers 

to “the capacity of a service provider or of an 

organization to understand and work effectively with the cultural beliefs and practices 

of persons from a given ethnic/racial group” 

(Castro et al. 1999, p. 504). Treatment 

providers working with individuals with COD 

should view these clients and their treatment 

in the context of their language, culture, ethnicity, geographic area, socioeconomic status, 

gender, age, sexual orientation, religion, spirituality, and any physical or cognitive disabilities. For a full discussion of cultural issues in 

treatment for persons with substance use disorders, see the forthcoming TIP Improving 

Cultural Competence in Substance Abuse 

Treatment (CSAT in development a). 

Cultural factors that may have an impact on 

treatment include heritage, history and experience, beliefs, traditions, values, customs, 

behaviors, institutions, and ways of communicating. The client’s culture may include distinctive ways of understanding disease or disorder, including mental and substance use 

disorders, which the provider needs to understand. Referencing a model of disease that is 

familiar to the client can help communication 

and enhance treatment. The counselor 

acquires cultural knowledge by becoming 

aware of the cultural factors that are important to a particular ethnic group or client. 

Cultural competence may be viewed as a continuum on which, through learning, the 

provider increases his or her understanding 

and effectiveness with different ethnic groups. 

Various researchers have described the markers on this continuum (Castro et al. 1999; 

Cross 1988; Kim et al. 1992). The continuum 

moves from cultural destructiveness, in which 

an individual regards other cultures as inferior to the dominant culture, through cultural 

incapacity and blindness to the more positive 

attitudes and greater levels of skill described 

below: 

•Cultural sensitivity is being “open to working with issues of culture and diversity” 

(Castro et al. 1999, p. 505). Viewed as a 

point on the continuum, however, a culturally sensitive individual has limited cultural 

knowledge and may still think in terms of 

stereotypes. 

•Cultural competence, when viewed as the 

next stage on this continuum, includes an 

ability to “examine and understand 

nuances” and exercise “full cultural empathy.” This enables the counselor to “understand the client from the client’s own cultural perspective” (Castro et al. 1999, p. 

505). 

•Cultural proficiency is the highest level of 

cultural capacity. In addition to understanding nuances of culture in even greater 

depth, the culturally proficient counselor 

also is working to advance the field through 

leadership, research, and outreach (Castro 

et al. 1999, p. 505). 

It is important to remember that clients, not 

counselors, define what is culturally relevant 

to them. It is possible to damage the relationship with a client by making assumptions, 

however well intentioned, about the client’s 

cultural identity. For example, a client of 

Hispanic origin may be a third-generation 

United States citizen, fully acculturated, who 

feels little or no connection with her Hispanic 

heritage. A counselor who assumes this client 

shares the beliefs and values of many 

Hispanic cultures would be making an erroneous generalization. Similarly, it is helpful to 

remember that all of us represent multiple 

cultures. Clients are not simply African– 

American, white, or Asian. A client who is a 

20-year-old African-American man from the 

rural south may identify, to some extent, with 

youth, rural south, or African-American culDefinitions, Terms, and Classification Systems for Co-Occurring Disorders 31 
tural elements—or may, instead, identify 

more strongly with another cultural element, 

such as his faith, that is not readily apparent. 

Counselors are advised to open a respectful 

dialog with clients around the cultural elements that have significance to them. 

Integrated Counselor 

Competencies 

A counselor has integrated competencies if he 

or she has the specific attitudes, values, knowledge, and skills needed to provide appropriate 

services to individuals with COD in the context 

of his or her actual job and program setting. 

Just as other types of integration exist on a 

continuum, so too does integrated competency. 

Some interventions and/or programs require 

clinicians only to have basic competency in welcoming, screening, assessing, and identifying 

treatment needs of individuals with COD. 

Other interventions, programs, or job functions (e.g., those of supervisory staff) may 

require more advanced integrated competency. 

The more complex or unstable the client, the 

more formal mechanisms are required to coordinate the various staff members working with 

that client in order to provide effective integrated treatment. 

A number of service delivery systems are 

moving toward identification of a required 

basic level of integrated competency for all 

clinicians in the mental health and substance 

abuse treatment systems. Many States also 

are developing curricula for initial and ongoing training and supervision to help clinicians 

achieve these competencies. Other State systems (e.g., Illinois) have created career ladders and certification pathways to encourage 

clinicians to achieve higher levels of integrated competency and to reward them for this 

achievement. (See chapter 3 for a full discussion of counselor competencies.) 

Terms Related to 

Programs 

A program is a formally organized array of services and interventions provided in a coherent 

manner at a specific level or levels of care in 

order to address the needs of particular target 

populations. Each program has its own staff 

competencies, policies, and procedures. 

Programs may be operated directly by public 

funders (e.g., States and counties) or by privately funded agencies. An individual agency 

may operate many different programs. Some 

agencies operate only mental health programs, 

some operate only substance abuse treatment 

programs, and some do both. An individual, 

licensed healthcare practitioner (such as a psychiatrist or psychologist) may offer her or his 

own integrated treatment services as an independent practitioner. 

Key Programs 

Mental health-based 

programs 

A mental health program is an organized array 

of services and interventions with a primary 

focus on treating mental disorders, whether by 

providing acute stabilization or ongoing treatment. These programs may exist in a variety of 

settings, such as traditional outpatient mental 

health centers (including outpatient clinics and 

psychosocial rehabilitation programs) or more 

intensive inpatient treatment units. 

Many mental health programs treat significant numbers of individuals with COD. 

Programs that are more advanced in treating 

persons with COD may offer a variety of 

interventions for substance use disorders 

(e.g., motivational interviewing, substance 

abuse counseling, skills training) within the 

context of the ongoing mental health treatment. 

32 Definitions, Terms, and Classification Systems for Co-Occurring Disorders 
Substance abuse treatment 

programs 

A substance abuse treatment program is an 

organized array of services and interventions 

with a primary focus on treating substance use 

disorders, providing both acute stabilization 

and ongoing treatment. 

Substance abuse treatment programs that are 

more advanced in treating persons with COD 

may offer a variety of interventions for mental 

disorders (e.g., psychopharmacology, symptom 

management training) within the context of the 

ongoing substance abuse treatment. 

Program Types 

The ASAM PPC-2R (ASAM 2001) describes 

three different types of programs for people 

with COD: 

•Addiction only services. This term refers to 

programs that “either by choice or for lack 

of resources, cannot accommodate patients 

who have mental illnesses that require 

ongoing treatment, however stable the illness and however well-functioning the 

patient” (ASAM 2001, p. 10). 

•Dual diagnosis capable (DDC) programs are 

those that “address co-occurring mental 

and substance-related disorders in their 

policies and procedures, assessment, treatment planning, program content and discharge planning” (ASAM 2001, p. 362). 

Even where such programs are geared primarily to treat substance use disorders, 

program staff are “able to address the 

interaction between mental and substancerelated disorders and their effect on the 

patient’s readiness to change—as well as 

relapse and recovery environment issues— 

through individual and group program content” (ASAM 2001, p. 362). 

•Dual diagnosis enhanced programs have a 

higher level of integration of substance 

abuse and mental health treatment services. 

These programs are able to provide primary substance abuse treatment to clients who 

are, as compared to those treatable in DDC 

programs, “more 

symptomatic 

and/or functionally A system is a means 

impaired as a 

result of their co- of organizing a 

occurring mental 

disorder” (ASAM number of different 

2001, p. 10).



Enhanced-level ser­
 treatment programs vices “place their



primary focus on



the integration of



services for mental



and substance- to implement a

specific mission and 

common goals. 

related disorders in 

their staffing, serand related services

vices and program 

content” (ASAM 

2001, p. 362). 

See chapter 3 for a 

discussion of program terminology proposed by the consensus 

panel that works well for both the substance 

abuse and mental health fields (i.e., “basic,” 

“intermediate,” and “advanced”) and for a 

crosswalk of this terminology with the ASAM 

program types. 

Terms Related to 

Systems 

For the purposes of this TIP, a system is a 

means of organizing a number of different 

treatment programs and related services to 

implement a specific mission and common 

goals. A basic example of a system is 

SAMHSA. Single State Agencies are systems 

that organize statewide services. There may 

also be county, city, or local systems in various areas. 

A system executes specific functions by providing services and related activities. It is 

often, but not always, a government agency. 

Systems may be defined according to a number of different characteristics: a section of 

government, a geographic entity, or a payor 

(e.g., the Medicaid system of care). 

Definitions, Terms, and Classification Systems for Co-Occurring Disorders 33 
Systems work with other systems in a variety 

of ways and with different degrees of integration. The primary systems with which people 

with COD interact are the substance abuse 

treatment and mental health services systems. 

Other systems that frequently come into play 

are health care, criminal justice, and social 

services. Systems are usually the entities that 

determine funding, standards of care, licensing, and regulation. 

Substance Abuse Treatment 

System 

The substance abuse treatment system encompasses a broad array of services organized 

into programs intended to treat substance use 

disorders (including illegal substances, such 

as marijuana and methamphetamine, and 

legal substances, such as alcohol for adults 

over 21 years of age). It also includes services 

organized in accord with a particular treatment approach or philosophy (e.g., 

methadone treatment for opioid dependence 

or therapeutic communities). A system may 

be defined by a combination of administrative 

leadership (e.g., through a designated director of substance abuse treatment services), 

regulatory oversight (e.g., all programs that 

have substance abuse treatment licenses), or 

funding (e.g., all programs that receive categorical substance abuse funding, or, more 

rarely, bill third-party payors for providing 

substance abuse services). 

In most substance abuse treatment systems, 

the primary focus is on providing distinct 

treatment episodes for the acute stabilization, 

engagement, active treatment, ongoing rehabilitation of substance use disorders, and 

relapse prevention. More intensive services 

are almost invariably targeted to the treatment of substance dependence. The primary 

focus of intervention is abstinence from illicit 

drugs for those who use illicit drugs and from 

alcohol for those who use alcohol excessively. 

Mental Health Service System 

The mental health service system includes a 

broad array of services and programs intended 

to treat a wide range of mental disorders. Like 

the substance abuse treatment system, the 

coherence of the mental health system is 

defined by a combination of administrative 

leadership (e.g., through a designated director 

of mental health services), regulatory oversight 

(e.g., all programs which have mental health 

licenses), and funding (e.g., all programs which 

receive categorical mental health funding or 

that primarily bill third party payors for providing mental health services). 

In most mental health systems, services are 

provided for a wide range of mental disorders; however, in many publicly financed 

mental health programs, the priority is on 

acute crisis intervention and stabilization and 

on the provision of ongoing treatment and 

rehabilitative services for individuals identified as having SPMI. Typically, the mental 

health system identifies a cohort of priority 

clients (identified by a State’s definition of 

SPMI) for which it assumes continuing 

responsibility, often by providing continuing 

case management, psychiatric rehabilitation 

services, and/or housing support services. 

Interlinking Systems 

Depending on the life area affected at a given 

moment, individuals with COD may present 

themselves at different venues. For example, a 

person who experiences an array of problems 

in addition to the COD—such as homelessness, 

legal problems, and general medical problems—may first be seen at a housing agency or 

medical clinic. Historically, the distinctive 

boundaries maintained between systems have 

impeded the ability of individuals with COD to 

access needed services (Baker 1991; Schorske 

and Bedard 1989). 

Intersystem linkages are essential to a comprehensive service delivery system. Fundamental 

to effective linkage is the collaboration between 

substance abuse treatment and mental health 

34 Definitions, Terms, and Classification Systems for Co-Occurring Disorders 
systems, because they are the primary care systems for persons with COD. The coordination 

of these systems enhances the quality of services by removing barriers that impede access 

to needed services. For example, access to care 

and quality of care have been impeded historically by the failure to address issues of language and culture. Intersystem coordination 

can lead to cohesive and coordinated delivery 

of program and services, where the burden is 

not on the individual to negotiate services and 

the system’s resources are used more effectively. The criminal justice system now plays a central role in the delivery of treatment for both 

mental health and substance use disorders, 

especially for those persons with COD, so it is 

important to ensure coordination with this system as well. Community health centers and 

other primary health providers also play critical roles in substance use disorder treatment 

and mental health treatment. 

Comprehensive Continuous 

Integrated System of Care 

The Comprehensive Continuous Integrated 

System of Care model (CCISC) is a model to 

bring the mental health and substance abuse 

treatment systems (and other systems, potentially) into an integrated planning process to 

develop a comprehensive, integrated system of 

care. The CCISC is based on the awareness 

that COD are the expectation throughout the 

service system. The entire system is organized 

in ways consistent with this assumption. This 

includes system-level policies and financing, the 

design of all programs, clinical practices 

throughout the system, and basic clinical competencies for all clinicians. This model derives 

from the work of the SAMHSA Managed Care 

Initiative Consensus Panel on developing standards of care for individuals with COD (Center 

for Mental Health Services 1998; Minkoff 

2001a). CCISCs are grounded in the following 

assumptions: 

• The four-quadrant model is a valid model for 

service planning. 

• Individuals with COD benefit from continuous, integrated treatment relationships. 

• Programs should provide integrated primary 

treatment for substance use and mental disorders in which interventions are matched to 

diagnosis, phase of recovery, stage of change, 

level of functioning, level of care, and the 

presence of external supports and/or contingencies. 

This model has been identified by SAMHSA as 

an exemplary practice and is at various stages 

of implementation in a number of States. States 

in various stages of implementing the CCISC 

model include Alabama, Alaska, Arizona, 

Maine, Maryland, Massachusetts, Montana, 

and New Mexico, as well as the District of 

Columbia. Regional projects are underway in 

Florida, Louisiana, Michigan, Oregon, Texas, 

and Virginia. 

Definitions, Terms, and Classification Systems for Co-Occurring Disorders 35 
3 Keys to Successful 

Programming 

In This 

Chapter... 

Guiding Principles



Delivery of



Services



Improving



Substance Abuse



Treatment Systems
 


and Programs



Workforce
 


Development and



Staff Support



Overview 

Many treatment agencies may recognize the need to provide quality care 

to persons with co-occurring disorders (COD), but see it as a daunting 

challenge beyond their resources. Programs that already have incorporated some elements of integrated services and want to do more may lack 

a clear framework for determining priorities. As programs look to 

improve their effectiveness in treating this population, what should they 

consider? How could the experience of other agencies inform their planning process? Are resources available that could help turn such a vision 

into reality? This chapter is designed both to help agencies that want to 

design programs for their clients with COD and to assist agencies that 

are trying to improve existing ones. 

The chapter begins with a review of guiding principles derived from 

proven models, clinical experience, and the growing base of empirical 

evidence. Building on these guiding principles, the chapter turns to the 

core components for effective service delivery. It suggests that the 

provider needs to address in concrete terms the challenges of providing 

access, assessment, appropriate level of care, integrated treatment, comprehensive services, and continuity of care. This section provides guidance relevant to designing processes that are appropriate for this population within each of these key areas. 

The chapter then moves onto a discussion of strategies for agencies that 

want to improve established systems, beginning with the too-familiar 

issue of how to access funding—a major hurdle for most, if not all, substance abuse treatment agencies. This portion of the chapter also gives 

an example of how one collaborative project crosses agency lines to 

share resources among a variety of partners and ensure continuity of 

care. The chapter then discusses difficulties of achieving equitable 

resource allocations for a venture of this nature, and highlights efforts to 

integrate research and practice. 

37 
Finally, the critical issues in workforce development are discussed, for without a well-prepared staff, the needs of these often-challenging 

clients cannot be met—regardless of what other 

systemic changes are made. The chapter 

describes the attitudes and values needed to 

successfully treat these clients, required competencies, paths to professional development for 

those who wish to increase their skills in treating clients with COD, and ways of avoiding 

staff burnout and reducing turnover—an especially pressing concern for providers who work 

closely with this demanding population. 


Guiding Principles 

The consensus panel developed a list of guiding



principles to serve as fundamental building 

blocks for programs that offer services to



clients with COD (see Figure 3-1). These princi-


ples derive from a variety of sources: conceptu­


al writings, well-articulated program models, a 


growing understanding of the essential features 


of COD, elements common to separate treat-


ment models, clinical experience, and available 


empirical evidence. These principles may be 


applied at both a program level (e.g., providing 


literature for people with cognitive impair-


ments) or at the individual level (e.g., address­


ing the client’s basic needs). 
 

In identifying these principles, the TIP consen­


sus panel recognizes that there are a number of



carefully elaborated protocols to guide treat­


ment for individuals with COD, including prin­


ciples identified by Drake and colleagues (1993)



and by the Center for Mental Health Services 


Managed Care Initiative Panel (1998), as well 


as the assumptions that underlie the model 


Comprehensive Continuous Integrated Systems 


of Care described in chapter 2. The principles 


suggested in this chapter are consistent with 


these protocols, but reflect the specific focus of 


the consensus panel on how best to provide 


COD treatment in substance abuse treatment 


agencies. (However, the principles apply equal-


ly well to the treatment of COD in mental 


health agencies.) 


The following section discusses each of the six 


principles in turn, highlighting the related field 


experience that underlies each one. 


Employ a Recovery 

Perspective

There are two main features of the recovery


perspective: It acknowledges that recovery is a


long-term process of internal change, and it


recognizes that these internal changes proceed


through various stages. (See De Leon 1996 and


Prochaska et al. 1992 for a detailed descrip­


tion. Also see chapter 5 of this TIP for a dis-


cussion of the recovery perspective as a guide-


line for practice.)


The recovery perspective is applicable to 

clients who have COD. It generates at least two

main principles for practice:


Figure 3-1 

Six Guiding Principles in Treating Clients With COD 

1. Employ a recovery perspective. 

2. Adopt a multi-problem viewpoint. 

3. Develop a phased approach to treatment. 

4. Address specific real-life problems early in treatment. 

5. Plan for the client’s cognitive and functional impairments. 

6. Use support systems to maintain and extend treatment effectiveness. 

38 Keys to Successful Programming 
Develop a treatment plan that provides for 

continuity of care over time. In preparing this 

plan, the clinician should recognize that treatment may occur in different settings over time 

(i.e., residential, outpatient) and that much of 

the recovery process typically occurs outside of 

or following treatment (e.g., through participation in mutual self-help groups and through 

family and community support, including the 

faith community). It is important to reinforce 

long-term participation in these continuous 

care settings. 

Devise treatment interventions that are specific 

to the tasks and challenges faced at each stage 

of the co-occurring disorder recovery process. 

Whether within the substance abuse treatment 

or mental health services system, the clinician 

is advised to use sensible stepwise approaches 

in developing and using treatment protocols. In 

addition, markers that are unique to individuals—such as those related to their cultural, 

social, or spiritual context—should be considered. It is important to engage the client in 

defining markers of progress meaningful to the 

individual and to each stage of recovery. 

Adopt a Multi-Problem 

Viewpoint 

People with COD generally have an array of 

mental health, medical, substance abuse, family, and social problems. Most are in need of 

substantial rehabilitation and habilitation (i.e., 

initial learning and acquisition of skills). 

Treatment should address immediate and longterm needs for housing, work, health care, and 

a supportive network. Therefore, services 

should be comprehensive to meet the multidimensional problems typically presented by 

clients with COD. 

Develop a Phased Approach 

to Treatment 

Many clinicians view clients as progressing 

though phases (Drake and Mueser 1996a; 

McHugo et al. 1995; Osher and Kofoed 1989; 

Sacks et al. 1998b). Generally, three to five 

phases are identified, including engagement, 

stabilization, treatment, and aftercare or continuing care. These phases are consistent 

with, and parallel to, stages identified in the 

recovery perspective. As noted above, use of 

these phases enables the clinician (whether 

within the substance abuse treatment or mental health services system) to develop and use 

effective, stage-appropriate treatment protocols. (See chapter 5 for a discussion of how to 

use motivational enhancement therapy appropriate to the client’s stage of recovery. Also 

see TIP 35, Enhancing Motivation for Change 

in Substance Abuse Treatment [Center for 

Substance Abuse Treatment (CSAT) 1999b]). 

Address Specific Real-Life 

Problems Early in Treatment 

The growing recognition that co-occurring disorders arise in a context of personal and social 

problems, with a corresponding disruption of 

personal and social life, has given rise to 

approaches that address specific life problems 

early in treatment. These approaches may 

incorporate case management and intensive 

case management to help clients find housing or 

handle legal and family matters. It may also be 

helpful to use specialized interventions that target important areas of client need, such as 

money management (e.g., Conrad et al. 1999) 

and housing-related support services (e.g., 

Clark and Rich 1999). Psychosocial rehabilitation, which helps the client develop the specific 

skills and approaches she needs to perform her 

chosen roles (e.g., student, employee, community member) also is a useful strategy for 

addressing these specific problems (Anthony 

1996; Cnaan et al. 1990). 

Solving such problems often is an important 

first step toward achieving client engagement in 

continuing treatment. Engagement is a critical 

part of substance abuse treatment generally 

and of treatment for COD specifically, since 

remaining in treatment for an adequate length 

of time is essential to achieving behavioral 

change. 

Keys to Successful Programming 39 
Plan for the Client’s Cognitive 

and Functional Impairments 

Services for clients with COD, especially those 

with more serious mental disorders, must be 

tailored to individual needs and functioning. 

Clients with COD often display cognitive and 

other functional impairments that affect their 

ability to comprehend information or complete 

tasks (CSAT 1998e; Sacks et al. 1997b). The 

manner in which interventions are presented 

must be compatible with client needs and functioning. Such impairments frequently call for 

relatively short, highly structured treatment 

sessions that are focused on practical life problems. Gradual pacing, visual aids, and repetition often are helpful. Even impairments that 

are comparatively subtle (e.g., certain learning 

disabilities) may still have significant impact on 

treatment success. Careful assessment of such 

impairments and a treatment plan consistent 

with the assessment are therefore essential. 

Use Support Systems To 

Maintain and Extend 

Treatment Effectiveness 

The mutual self-help movement, the family, the 

faith community, and other resources that exist 

within the client’s community can play an 

invaluable role in recovery. This can be particularly true for the client with COD, as many 

clients with COD have not enjoyed a consistently supportive environment for decades. In some 

cultures, the stigma surrounding substance use 

or mental disorders is so great that the client 

and even the entire family may be ostracized 

by the immediate community. Furthermore, the 

behaviors associated with active substance use 

may have alienated the client’s family and community. The clinician plays a role in ensuring 

that the client is aware of available support systems and motivated to use them effectively. 

Mutual self-help 

Based on the Alcoholics Anonymous model, the 

mutual self-help movement has grown to 

encompass a wide variety of addictions. 

Narcotics Anonymous and Cocaine Anonymous 

are two of the largest mutual self-help organizations for substance use disorders; Recoveries 

Anonymous and Schizophrenics Anonymous 

are among the best known for mental illness. 

Personal responsibility, self-management, and 

helping one another are the basic tenets of 

mutual self-help approaches. Such programs 

apply a broad spectrum of personal responsibility and peer support principles, usually 

including 12-Step methods that prescribe a 

planned regimen of change (see Peyrot 1985 for 

the history, structure, and approach of 

Narcotics Anonymous, representative of 12­

Step approaches in general). However, in the 

past clients with COD felt that either their mental health or their substance use issues could 

not be addressed in a single-themed mutual 

self-help group; that has changed. 

Mutual self-help principles, highly valued in 

the substance abuse treatment field, are now 

widely recognized as important components in 

the treatment of COD. Mutual self-help groups 

may be used as an adjunct to primary treatment, as a continuing feature of treatment in 

the community, or both. These groups not only 

provide a vital means of support during outpatient treatment, but also are used commonly in 

residential programs such as therapeutic communities. As clients gain employment, travel, 

or relocate, mutual self-help meetings may 

become the most easily accessible means of providing continuity of care. For a more extensive 

discussion of dual recovery mutual self-help 

programs applicable to persons with COD, see 

chapter 7. 

Building community 

The need to build an enduring community arises from three interrelated factors—the persistent nature of COD, the recognized effectiveness of mutual self-help principles, and the 

importance of client empowerment. The therapeutic community (TC), modified mutual selfhelp programs for COD (e.g., Double Trouble 

in Recovery), and the client consumer movement all reflect an understanding of the critical 

role clients play in their own recovery, as well 

40 Keys to Successful Programming 
as the recognition that support from other 

clients with similar problems promotes and sustains change. 

Reintegration with family 

and community 

The client with COD who successfully completes treatment must face the fragility of 

recovery, the toxicity of the past environment, 

and the negative impact of previous associates 

who may encourage drug or alcohol use and 

illicit or maladaptive behaviors. There is a 

need for groups and activities that support 

change. In this context it is important that 

these clients receive support from family and 

significant others where that support is available or can be developed. There is also the 

need to help the client reintegrate into the community through such resources as religious, 

recreation, and social organizations. (See chapter 6 for a discussion of continuing care issues 

in treatment.) 

Delivery of Services 

While the guiding principles described above 

serve as the fundamental building blocks for 

effective treatment, ensuring effective treatment requires attention to other variables. This 

section discusses six core components that form 

the ideal delivery of services for clients with 

COD. These include: 

1. Providing access 

2. Completing a full assessment 

3. Providing an appropriate level of care 

4. Achieving integrated treatment 

5. Providing comprehensive services 

6. Ensuring continuity of care 

It is important

that clients receive

support from family and significant

others where that 

support is 

available or can 

be developed.

Providing Access 

“Access” refers to the process by which a person with COD makes initial contact with the 

service system, receives an initial evaluation, 

and is welcomed into services that are appropriate for his or her needs. 

Access occurs in four main ways: 

1. Routine access for individuals seeking services who are not in crisis 

2. Crisis access for individuals requiring immediate services due to an emergency 

3. Outreach, in which agencies target individuals in great need (e.g., people who are 

homeless) who are not seeking services or 

cannot access ordinary routine or crisis services 

4. Access that is involuntary, coerced, or mandated by the criminal justice system, 

employers, or the child welfare system 

Treatment access may 

be complicated by 

clients’ criminal justice involvement, 

homelessness, or 

health status. CSAT’s 

“no wrong door” policy should be applied 

to the full range of 

clients with COD, and 

programs should 

address obstacles that 

bar entry to treatment 

for either the mental 

or substance use disorders. (See chapter 7 

for recommendations 

on removing systemic 

barriers to care and 

the text box on p. 42 

for more on CSAT’s 

“no wrong door” 

policy.) 

Completing a Full Assessment 

While chapter 4 provides a complete description of the assessment process, this section 

highlights several important features of assessment that must be considered in the context of 

effective service delivery. Assessment of individuals with COD involves a combination of the 

following: 

Keys to Successful Programming 41 
•Screening to detect the possible presence of 

COD in the setting where the client is first 

seen for treatment 

•Evaluation of background factors (family, 

trauma history, marital status, health, education and work history), mental disorders, 

substance abuse, and related medical and 

psychosocial problems (e.g., living circumstances, employment, family) that are critical 

to address in treatment planning 

•Diagnosis of the type and severity of substance use and mental disorders 

•Initial matching of individual client to services (often, this must be done before a full 

assessment is completed and diagnoses clarified; also, the client’s motivation to change 

with regard to one or more of the co-occurring disorders may not be well established) 

•Appraisal of existing social and community 

support systems 

•Continuous evaluation (that is, re-evaluation 

over time as needs and symptoms change and 

as more information becomes available) 

The challenge of assessment for individuals 

with COD in any system involves maximizing 

the likelihood of the identification of COD, 

immediately facilitating accurate treatment 

planning, and revising treatment over time as 

the client’s needs change. 

Providing an Appropriate 

Level of Care 

Clients enter the treatment system at various 

levels of need and encounter agencies with 

varying capacity to meet those needs. Ideally, 

clients should be placed in the level of care 

appropriate to the severity of both their substance use disorder and their mental illness. 

The American Society of Addiction Medicine’s 

(ASAM) classification is one standard way of 

identifying programs that offer the needed services. As described in chapter 2, ASAM 

describes programs’ ability to address COD as 

“addiction only services,” “dual diagnosis 

capable,” and “dual diagnosis enhanced.” 

Making “No Wrong Door” a Reality 

CSAT’s “no wrong door” policy states that effective systems must ensure that an individual needing treatment 

will be identified and assessed and will receive treatment, either directly or through appropriate referral, no 

matter where he or she enters the realm of services (CSAT 2000a). The consensus panel strongly endorses this 

policy. 

The focus of the “no wrong door” imperative is on constructing the healthcare delivery system so that treatment 

access is available at any point of entry. A client with COD needing treatment might enter the service system by 

means of primary healthcare facilities, homeless shelters, social service agencies, emergency rooms, or criminal 

justice settings. Some clients require the creation of a “right door” for treatment entry—for example, mobile 

outreach teams who can access clients with COD who are unlikely to knock on the door of any treatment facility. 

The “no wrong door” approach has five major implications for service planning: 

1. Assessment, referral, and treatment planning for all settings must be consistent with a “no wrong door” policy. 

2. Creative outreach strategies may be needed to encourage some people to engage in treatment. 

3. Programs and staff may need to change expectations and program requirements to engage reluctant and 

“unmotivated” clients. 

4. Treatment plans should be based on clients’ needs and should respond to changes as they progress through 

stages of treatment. 

5. The overall system of care needs to be seamless, providing continuity of care across service systems. This can 

only be achieved through an established pattern of interagency cooperation or a clear willingness to attain 

that cooperation. 

42 Keys to Successful Programming 
While recognizing ASAM’s contribution, the 

consensus panel suggests an alternative classification system: basic, intermediate, advanced, 

or fully integrated. As conceived by the consensus panel 

•A basic program has the capacity to provide 

treatment for one disorder, but also screens 

for the other disorder and can access necessary consultations. 

•A program with an intermediate level of 

capacity tends to focus primarily on one 

disorder without substantial modification to 

its usual treatment, but also explicitly 

addresses some specific needs of the other 

disorder. For example, a substance abuse 

treatment program may recognize the 

importance of continued use of psychiatric 

medications in recovery, or a psychiatrist 

could provide motivational interviewing 

regarding substance use while prescribing 

medication for mental disorders. 

•A program with an advanced level of capacity provides integrated substance abuse 

treatment and mental health services for 

clients with COD. Several program models 

of this sort are described in chapter 6. 

Essentially, these programs address COD 

using an integrated perspective and provide 

services for both disorders. This usually 

means strengthening substance abuse treatment in the mental health setting by adding 

interventions such as mutual self-help and 

relapse prevention groups. It also means 

adding mental health services, such as psychoeducational classes on mental disorder 

symptoms and groups for medication monitoring, in substance abuse treatment settings. Collaboration with other agencies 

may add to the comprehensiveness of services. 

•A program that is fully integrated actively 

combines substance abuse and mental 

health interventions to treat disorders, 

related problems, and the whole person 

more effectively. 

The suggested classification has several advantages. For one, it avoids the use of the term 

“dual diagnosis” (instead of COD) and allows a 

more general, flexible approach to describing 

capacity without specific criteria. In addition, 

the recommended classification system conceptualizes a bidirectionality of movement where 

either substance abuse or mental health agencies can advance toward more integrated care 

for clients with COD, as shown in Figure 3-2 

(p. 44). 

Figure 3-2 depicts a model of basic, intermediate (COD capable), and advanced (COD 

enhanced) programming within mental health 

services and substance abuse treatment systems. The idea of integrated COD treatment is 

shown in the center. For the purpose of this 

TIP, both mental health and substance abuse 

treatment providers may be conceived of as 

beginning, intermediate, or advanced in terms 

of their progress toward the highest level of 

capacity to treat persons with COD. 

It should also be recognized that not all services want or need to be fully integrated, since 

many clients do not need a full array of services. (See Figure 2-1 in chapter 2.) In Figure 

3-2, the middle box—fully integrated—refers 

to a system that has achieved an integrated setting in which staff, administration, regulations, 

and funding streams are fully integrated. 

Achieving Integrated 

Treatment 

The concept of integrated treatment for persons with severe mental disorders and substance use disorders, as articulated by Minkoff 

(1989), emphasized the need for correlation 

between the treatment models for mental health 

services and substance abuse treatment in a 

residential setting. Minkoff’s model stressed the 

importance of well-coordinated, stage-specific 

treatment (i.e., engagement, primary treatment, continuing care) of substance use and 

mental disorders, with emphasis on dual recovery goals as well and the use effective treatment 

strategies from both the mental health services 

and the substance abuse treatment fields. 

During the last decade integrated treatment 

continued to evolve. Several successful treatment models have been described for addiction 

settings (Charney et al. 2001; McLellan et al. 

Keys to Successful Programming 43 
Figure 3-2 

Levels of Program Capacity in Co-Occurring Disorders 

1993; Saxon and Calsyn 1995; Weisner et al. 

2001), including the addition of psychiatric and 

mental health services to methadone treatment 

(Kraft et al. 1997; Woody et al. 1983), and a 

modified therapeutic community for providing 

integrated care to persons with COD (De Leon 

1993b; Guydish et al. 1994; Sacks 2000; Sacks 

et al. 1997a, b, 1998a, 2002). Likewise, the literature also describes numerous models for 

mental health settings (CSAT 1994a; Drake and 

Mueser 1996b; Lehman and Dixon 1995; 

Minkoff and Drake 1991; Zimberg 1993). 

Figure 3-3 illustrates one vision of a comprehensive, fully integrated approach to treatment 

for persons with severe mental disorders and 

substance use disorders from the mental health 

literature. However, as noted in the following 

section, programs may be integrated in a variety of ways. 

The literature from both the substance abuse 

and mental health fields has evolved to 

describe integrated treatment as a unified 

treatment approach to meet the substance 

abuse, mental health, and related needs of a 

client. It is the preferred model of treatment. 

Integrated treatment can occur on different 

levels and through different mechanisms. For 

example: 

• One clinician delivers a variety of needed

services.

• Two or more clinicians work together to provide needed services.

• A clinician may consult with other specialties

and then integrate that consultation into the

care provided.

• A clinician may coordinate a variety of efforts

in an individualized treatment plan that integrates the needed services. For example, if

someone with housing needs was not accepted

at certain facilities, the clinician might work

with a State-level community-housing program to find the transitional or supported

housing the client needs.

• One program or program model (e.g., modified TC or Assertive Community Treatment)

can provide integrated care.

• Multiple agencies can join together to create a

program that will serve a specific population.

For example, a substance abuse treatment

program, a mental health center, a local

44 Keys to Successful Programming 
housing authority, a foundation, a county 

government funding agency, and a neighborhood association could join together to establish a treatment center to serve women with 

COD and their children. 

Integrated treatment also is based on positive 

working relationships between service 

providers. The National Association of State 

Mental Health Program Directors 

(NASMHPD) and the National Association of 

State Alcohol and Drug Abuse Directors’ 

(NASADAD) four-quadrant category framework described in chapter 2 provides a useful 

structure for fostering consultation, collaboration, and integration among systems and 

providers to deliver appropriate care to every 

client with COD (see chapter 2, Figure 2-1). 

According to the NASMHPD–NASADAD 

(1999) framework 

•Consultation refers to the traditional types 

of informal relationships among 

providers—from referrals to requests for 

exchanging information and keeping each 

other informed. The framework calls for 

particular attention to the consultation 

relationship during identification, engagement, prevention, and early intervention 

activities. 

•Collaboration is essential when a person 

who is receiving care in one treatment setting also requires services from another 

provider. Collaboration is distinguished 

from consultation on the basis of the formal 

quality of collaborative agreements, such as 

memoranda of understanding or service 

contracts, which document the roles and 

responsibilities each party will assume in a 

continuing relationship. For example, parties must ensure that they can share information without violating Federal Law 42 

C.F.R. Part 2 on confidentiality (see 

appendix K for more information). This will 

require the client to give written authorization for release of information to all 

providers. 

•Integration denotes “those relationships 

among mental health and substance abuse 

providers in which the contributions of professionals in both fields are moved into a 

single treatment setting and treatment regimen” (p. 15). 

Figure 3-3 

A Vision of Fully Integrated Treatment for COD 

• The client participates in one program that provides treatment for both disorders. 

• The client’s mental and substance use disorders are treated by the same clinicians. 

• The clinicians are trained in psychopathology, assessment, and treatment strategies for both mental and substance use disorders. 

• The clinicians offer substance abuse treatments tailored for clients who have severe mental disorders. 

• The focus is on preventing anxiety rather than breaking through denial. 

• Emphasis is placed on trust, understanding, and learning. 

• Treatment is characterized by a slow pace and a long-term perspective. 

• Providers offer stagewise and motivational counseling. 

• Supportive clinicians are readily available. 

• 12-Step groups are available to those who choose to participate and can benefit from participation. 

• Neuroleptics and other pharmacotherapies are indicated according to clients’ psychiatric and other medical 

needs. 

Source: Adapted from Drake et al. 1998b, p. 591. 

Keys to Successful Programming 45 
For the purposes of this TIP, integration is seen 

as a continuum. Depending on the needs of the 

client and the constraints and resources of particular systems, appropriate degrees and means 

of integration will differ. 

Providing Comprehensive 

Services 

People with COD have a range of medical and 

social problems—multidimensional problems 

that require comprehensive services. In addition to treatment for their substance use and 

mental disorders, these clients often require a 

variety of other services to address other social 

problems and stabilize their living conditions. 

Treatment providers should be prepared to 

help clients access a broad array of services, 

including life skills development, English as a 

second language, parenting, nutrition, and 

employment assistance. 

McLellan and colleagues have shown the need 

for wraparound services to address difficult-totreat public-sector clients, not all of whom were 

diagnosed with COD (Gould et al. 2000; 

McLellan et al. 1997). Two areas of particular 

value, highlighted below, are housing and 

work. 

Housing 

The high proportion of homelessness among 

clients with COD has focused attention on the 

importance of providing housing for people 

with COD and of integrating housing into treatment. Approaches vary from those that provide 

housing at the point of entry into the service 

system combined with case management and 

supportive services (Tsemberis and Asmussen 

1999), to those that provide housing as a 

reward contingent on successful completion of 

treatment (Milby et al. 1996; Schumacher et al. 

1995), or as part of a continuing care strategy 

that combines housing and continuing care services (Sacks et al. 1998a, 2003a). 

Addressing housing needs requires an ongoing 

relationship with housing authorities, landlords, and other housing providers. Groups 

and seminars that discuss housing issues also 

may be necessary to help clients with COD 

transition from residential treatment to housing. Another effective strategy for easing the 

transition has been organizing and coordinating housing tours with supportive housing programs. Finally, relapse prevention efforts are 

essential, since substance abuse generally disqualifies clients from public housing in the 

community. 

Work 

Vocational rehabilitation has long been one of 

the services offered to clients recovering from 

mental disorders and, to some degree, to those 

recovering from substance use disorders. 

However, in the past clients often were expected first to maintain a period of abstinence. As a 

result of this policy, people with serious mental 

disorders often were underserved, if served at 

all (CSAT 2000c). For people with COD, 

Blankertz and colleagues contend that, “work 

can serve as a rehabilitative tool and be an 

integral part of the process of stabilizing the 

mental illness and attaining sobriety” 

(Blankertz et al. 1998, p. 114). 

The fact is that many individuals with COD 

are unemployed. However, it is unreasonable 

to expect employers to tolerate employees who 

are actively using alcohol on the job or who 

violate their drug-free workplace policies. 

Therefore, if work is to become an achievable 

goal for individuals with COD, vocational 

rehabilitation and substance abuse treatment 

must be closely integrated into mental health 

rehabilitation (Blankertz et al. 1998). For 

more information about incorporating vocational rehabilitation into treatment, see TIP 

38, Integrating Substance Abuse Treatment 

and Vocational Services (CSAT 2000c). 

46 Keys to Successful Programming 
Ensuring Continuity of Care 

Continuity of care implies coordination of care 

as clients move across different service systems 

(e.g., Morrissey et al. 1997). Since both substance use and mental disorders frequently are 

long-term conditions, treatment for persons 

with COD should take into consideration rehabilitation and recovery over a significant period 

of time. Therefore, to be effective, treatment 

must address the three features that characterize continuity of care: 

•Consistency between primary treatment and 

ancillary services 

•Seamlessness as clients move across levels of 

care (e.g., from residential to outpatient 

treatment) 

•Coordination of present and past treatment 

episodes 

It is important to set up systems that prevent 

gaps between service system levels and between 

clinic-based services and those outside the clinic. The ideal is to include outreach, employment, housing, health care and medication, 

financial supports, recreational activities, and 

social networks in a comprehensive and integrated service delivery system. 

Empirical evidence related to 

continuity of care 

Evidence for the benefits of ensuring continuity 

of care comes from multiple sources. In one 

study of criminal justice populations not specifically identified as having COD, Wexler and 

colleagues (1999) found that at 3 years posttreatment only 27 percent of those prison program completers who also completed an aftercare program were returned to custody. In contrast, about three-fourths of the subjects in all 

other study groups were returned. Similar 

findings have been reported by Knight and colleagues (1999). Although selection bias exists in 

these studies for entry into aftercare, the longterm outcomes suggest the critical role of aftercare in maintaining positive treatment effects in 

the criminal justice population. 

A study of homeless 

clients with COD provided further evidence (again with 

selection bias into 

aftercare) that aftercare is crucial to positive treatment outcomes. In this study, 

clients who lived in 

supported housing 

after residing in a 

modified therapeutic 

community demonstrated reductions in 

antisocial behavior 

occurring during the 

residential modified 

therapeutic community program and stabilizing 

during supported housing, while increases in 

prosocial behavior were largely incremental 

and continuous throughout both the residential 

and supported housing programs (Sacks et al. 

2003a). 

Continuity of care

implies coordination of care as 

clients move 

across different 

service systems.

Organizing continuity of care 

In organizing continuity of care—a high-priority aspect of any treatment plan for a client with 

COD—the substance abuse treatment agency 

must carefully consider and strive to overcome 

systemic barriers. It is important to recognize 

that the public mental health and substance 

abuse treatment systems have evolved in different ways, and these differing histories must be 

recognized as collaborative ventures are 

formed. 

Community mental health centers were created to be relatively comprehensive in nature, 

but have not been funded to deliver comprehensive services. Furthermore, there are wide 

variations in the types of mental disorders 

that publicly funded mental health centers 

are permitted to treat; many restrict their 

services to those in acute crisis or who have 

serious and persistent mental illnesses, such 

as schizophrenia, bipolar affective disorder, 

or major depression. Many States explicitly 

prevent public mental health programs from 

Keys to Successful Programming 47 
treating those with primary substance use disorders. 

Substance abuse treatment programs exist 

within a variety of organizational structures. 

Many of them are stand-alone substance abuse 

treatment programs, several are part of comprehensive drug treatment agencies, some are 

affiliated with hospitals, some are located within hospitals, many have evolved as part of the 

criminal justice system, some exist in community mental health settings, and still others are 

faith-based programs. Many substance abuse 

treatment programs are the last refuge of the 

most underserved populations (e.g., the homeless). 

The different organizational structures and settings in which services occur influence the ease 

or difficulty of providing a service delivery network that is integrated, comprehensive, and 

continuous. Many of the larger drug treatment 

agencies are to be commended for developing 

state-of-the-art programming for COD, and 

some smaller programs also have extended 

themselves to serve this population. Nevertheless, the strains imposed by organizational and 

system constraints should be recognized. As 

substance abuse treatment agencies continue to 

develop their capabilities for treating clients 

with COD, the consensus panel recommends 

that groups of providers organize themselves 

into coherent systems of care that enable them 

to provide comprehensive services. 

An example of a collaborative that promotes 

the development of a local infrastructure in 

support of co-occurring treatment is the CoOccurring Collaborative of Southern Maine. 

The Collaborative’s ways of working, accomplishments, and the critical elements for success identified at the close of Figure 3-4 may 

well inspire others to weave similar structures, 

crossing agency boundaries to better serve 

shared clients. 

Improving Substance 

Abuse Treatment 

Systems and Programs 

Critical challenges face substance abuse treatment systems and programs that are intent on 

improving care for clients with COD. One of 

the most critical of these is how to organize a 

system that will provide continuity of care for 

these clients, who, as noted previously, often 

have multifaceted needs and require long-term 

treatment plans. Another, of course, is how to 

access funding for program improvement. 

When treatment providers from different systems cooperate, equitable allocation of funds 

also becomes an issue. Finally, at every level 

there is the problem of how best to integrate 

research and practice to give clients the benefit 

of the proven treatment strategies. This section 

addresses each of these major concerns in turn. 

Assessing the Agency’s 

Potential To Serve Clients 

With COD 

Every agency that already is treating or planning to treat clients with COD should assess the 

current profile of its clients, as well as the estimated number and type of potential new clients 

in the community. It also must consider its current capabilities, its resources and limitations, 

and the services it wants to provide in the 

future. 

Programs should consider performing a needs 

assessment to determine the prevalence of COD 

in their client population, the demographics of 

those clients, and the nature of the disorders 

and accompanying problems they present. 

These data help create a picture of client needs 

that can be useful not only to the agency itself, 

but also to other systems of care at various levels. All levels of government demand some form 

of needs assessment from provider agencies. 

Block grant requirements from the Federal 

government require a statewide needs assessment. In turn, States look to regional and 

county groups to perform a needs assessment 

48 Keys to Successful Programming 
Figure 3-4 

The Co-Occurring Collaborative of Southern Maine 

The Co-Occurring Collaborative of Southern Maine, a 501(c)(3) nonprofit corporation, is an alliance of member 

agencies, consumers, and family members in Cumberland County in southern Maine. Formed in 1992 through 

a State initiative on COD, the Collaborative provided the umbrella structure for a demonstration grant from 

The Bingham Program and The Robert Wood Johnson Foundation. It received additional support from 

Maine’s Office of Substance Abuse and Maine’s Medicaid Program for a project comparing the efficacy of integrated and coordinated care. The Collaborative has continued its work beyond the 3-year demonstration grant 

with funding from the Maine Office of Substance Abuse, becoming an integral part of the community’s efforts to 

address COD. In 1998, the Collaborative formalized its structure by becoming a Maine nonprofit corporation. 

The number of member agencies has expanded from an initial dozen to more than 30, including consumer 

groups, family groups, and mental health, substance abuse, criminal justice, HIV, and public health service 

providers. Each member agency has an identified liaison who serves as the bridge between the Collaborative 

and the agency. Each member agency formally commits through a memorandum of understanding to do the following: 

1. Support the Collaborative’s mission. 

2. Examine and make changes to the services and organizational structures to support improved service provision for persons with COD. 

3. Exchange information, share resources, and alter activities to enhance the capacities of all agencies to 

improve services for persons with COD. 

4. Participate actively in, and share responsibility for, the Collaborative. 

The Collaborative structure provides a mechanism for cross-agency and cross-disciplinary communication, 

coordination, training and education, creative interagency problemsolving, resource development for co-occurring recovery capacity, and advocacy. The Collaborative’s accomplishments to date include 

•Promoting dual competence expectations in the workforce 

•Obtaining grants and collaborating on grant submission 

•Expanding consumer, family, and provider partnerships 

•Developing the mutual self-help option of dual recovery 

•Supporting diversion planning from the criminal justice system 

•Supporting the creation of an Assertive Community Treatment team for individuals with COD 

•Creating a community service consultation team 

•Supporting transfer of knowledge to develop new clinical models for treatment of persons with personality 

and substance use disorders 

To achieve success in forging a collaborative structure, the following were found to be critical elements: 

•Inviting all relevant agencies to participate and air their concerns 

•Nurturing one-to-one relationships among service providers across service sectors 

•Creating and maintaining a shared knowledge base and a common vision 

•Collaboration, support, and empowerment 

•Early and frequent successes 

•Encouraging participation in planning and decisionmaking 

•Clarifying roles and process 

•Ensuring ongoing consumer and family participation 

•Conducting periodic self-review 

•Having visionary, consistent, and effective leadership 

Keys to Successful Programming 49 
focused on the local level. Local needs assessment information feeds back to the State level 

and is used to develop a statewide picture that, 

in turn, is provided to higher-level funding 

authorities. The data generated through needs 

assessments also can be used to demonstrate 

need in support of grant proposals for increasing service capacity prepared by the treatment 

agency. 

It is important to determine what changes need 

to be made with respect to staff, training, 

accreditation, and other factors to provide 

effective services for clients with COD. The 

agency also should know what resources and 

services are already available within their local 

and State systems of care before deciding what 

services to provide. This assessment of community capacity and the resulting decisionmaking 

process should involve all stakeholders in the 

program. Whatever changes the provider 

decides to make will require an active commitment from all levels of staff as well as from 

members of the community, advocacy groups, 

and other interested parties. 

The various classification systems described 

previously can be used to identify missing levels 

of care and gaps in specific services. Such tools 

permit clinicians to relate program services to 

clients’ needs for specific activities. They also 

enable planners to identify gaps in the current 

system of care and then to design programs 

that address these gaps. Figure 3-5 provides a 

list of domains and questions to guide agencies 

in assessing their potential to serve clients with 

COD. In doing so, it is assumed that each agency will use the best approach to each task that 

is possible, given its level of resources. It may, 

for example, need to use estimates rather than 

precise data in some instances. 

Accessing Funding 

System components and financing 

principles 

Both mental health services and substance 

abuse treatment systems must face the challenge of obtaining funding that supports programming for clients with COD. For substance 

abuse treatment agencies, which are seeing 

more clients with COD and clients with more 

serious COD, it often is difficult to obtain funds 

to provide needed screening, assessment, specialized mental health service enhancement, 

and case management. 

Developing a comprehensive system of care for 

people with COD requires committed leadership, joint planning, and the willingness and 

ability to find creative solutions to difficult 

problems. Financing a comprehensive system 

of care requires no less a commitment of time, 

creativity, and expertise. The process of continuing dialog between NASMHPD and 

NASADAD has identified key system development components and financing principles 

shown in Figure 3-6 (p. 52). Like the conceptual framework, these components and principles 

represent a set of flexible guidelines that can be 

adapted for use in any State or community. 

Each of the six financing principles is a critical 

element of success and is described below: 

1. Plan To Purchase Together. It has been

found that “in most successful demonstration programs for people with co-occurring

disorders, the State mental health agency

and the State alcohol and drug abuse

agency jointly planned and purchased services” (NASMHPD and NASADAD 2000,

pp. 19–20).

2. Define the Population. Individuals with

COD may fall into any of the four quadrants. Program services must target populations based on the severity of their mental or substance use disorders, among

other considerations. However, it is important to keep in mind that due to the illegality of drug use denying services to those

whose current condition is not severe may

increase the severity of problems associated with that drug use, increasing severity

by producing arrests, job loss, and conflicts with the child welfare system.

3. Secure Financing. The following section of

this chapter will provide some suggestions

on this challenging and often complex

task.

50 Keys to Successful Programming 
Figure 3-5 

Assessing the Agency’s Potential To Serve Clients With COD 

1. Describe the profile of current clients with COD and any potential changes anticipated. 

• Estimate the prevalence of persons with COD among the agency’s clients. (One of the screening tools
 


recommended in chapter 4 may be appropriate for this purpose.) 
 

• What are the demographics of persons with COD? 

• What functional problems do they have? 

• Are there clients with COD who seek care at the agency who are referred elsewhere? What is the profile 

of these clients? 

2. Identify services needed by clients. 

• What services are needed by existing and potential clients? 

3. Identify and assess resources available to meet client needs. 

• What services are immediately available to the program? 

• What services could be added within the program? 

• What services are available from the community that would enhance care? 

• How well are outside agencies meeting clients’ needs? 

4. Assess resource gaps. 

• What resources are needed to enhance treatment for persons with COD? 

• What can your agency, specifically, do to enhance its capacity to serve these clients? 

5. Assess capacity. 

• Realistically assess the capacity of your agency to address these resource gaps. 

6. Develop a plan to enhance capacity to treat clients with COD. 

• How can the skills of existing staff be increased? 

• Can additional expertise be accessed through consulting agreements or similar arrangements? 

• What additional programs or services can be offered? 

• What sources of funding might support efforts to enhance capacity? 

4. 	Purchase Effective Services. It is important to purchase services that research has 

shown to be effective. Unfortunately, COD 

research tends to focus on those with serious mental disorders. As a result, guidance on which strategies are most costeffective in treating persons with less serious mental disorders and co-occurring 

substance use disorders is not readily 

available. 

5. 	Purchase Performance. NASMHPD and 

NASADAD strongly recommend perforKeys to Successful Programming 

mance-based contracts that focus on outcomes. “A program’s effectiveness should 

be judged not only by how many people it 

serves or units of service it delivers, but 

rather by the level of real change it helps 

bring about in the lives of consumers who 

have co-occurring mental health and substance use disorders” (NASMHPD and 

NASADAD 2000). 

6. 	Evaluate and Improve. It is essential to 

evaluate performance. Findings help 

providers revise protocols to get better 

51 
Figure 3-6 

Financing a Comprehensive System of Care for People With COD 

Source: NASMHPD and NASADAD 2000, p. 19. 

Key System Development Components 

• Provide Leadership/Build Consensus 

• Identify Resources 

• Develop New Models/Train Staff 

• Decide on Outcomes 

• Evaluate Program 

Financing Principles 

• Plan To Purchase Together 

• Define the Population 

• Secure Financing 

• Purchase Effective Services 

• Purchase Performance 

• Evaluate and Improve 

results and give them a vital two-way 

channel for communicating with key stakeholders (NASMHPD and NASADAD 

2000). 

Federal funding 
 

opportunities



Federal funding opportunities include a variety 

of grants from diverse agencies. In its efforts to 

enhance services, the Substance Abuse and 

Mental Health Services Administration 

(SAMHSA) is currently emphasizing the use of 

strategies that have been demonstrated to be 

effective in research (“science to service”). 

Other Federal agencies such as the National 

Institutes of Health (NIH), including the 

National Institute on Drug Abuse (NIDA) and 

the National Institute on Alcohol Abuse and 

Alcoholism (NIAAA), and the National Institute 

of Mental Health (NIMH), emphasize funds for 

research and likely will provide only modest 

funds for treatment—typically in conjunction 

with research projects. Overall, SAMHSA will 

focus on working with States and helping communities use the latest research findings to 

implement effective treatment and prevention 

programs, while NIH institutes will conduct 

research on best practices in substance abuse 

treatment, prevention, and mental health services. The reader can determine what funding 

opportunities are currently available by visiting 

funder Web sites (e.g., SAMHSA’s Web site at 

http://www.samhsa.gov, NIDA’s Web site at 

http://www.nida.nih.gov, NIAAA’s Web site at 

http://www.niaaa.nih.gov, and NIMH’s Web 

site at http://www.nimh.nih.gov). 

Although SAMHSA and NIH probably will 

remain the main Federal funding sources for 

initiatives related to people with COD, other 

Federal agencies also may provide funding 

opportunities. Examples of such Federal agencies include the Health Resources and Services 

Administration within the U.S. Department of 

Health and Human Services, the U.S. 

Department of Justice, the U.S. Department of 

Labor, and so on. The reader can determine 

what funding opportunities are currently available by visiting the Web sites of these agencies 

or by searching the Catalog of Federal 

Domestic Assistance Web site 

(http://www.cfda.gov), which provides a 

database of all Federal programs available to 

State and local governments (including the 

District of Columbia); federally recognized 

Indian tribal governments; Territories (and 

possessions) of the United States; domestic 

public, quasi-public, and private profit and 

nonprofit organizations and institutions; specialized groups; and individuals. 

State funding opportunities 

Administrators or treatment professionals 

should be familiar with the funding mechanisms in their State. Information is also avail52 Keys to Successful Programming 
able through the National Association of State 

Alcohol/Drug Abuse Directors 

(http://www.nasadad.org) and the National 

Association of State Mental Health Program 

Directors (http://www.nasmhpd.org). 

Private funding 

opportunities 

Foundation matching funds can be used to 

leverage change within a system in specific 

areas and increasingly should be explored in 

the area of COD treatment. For example, 

Robert Wood Johnson Foundation funding has 

driven improved access to primary care within 

addiction services. 

A wide variety of funding initiatives exist in 

health care, including in the area of substance 

abuse treatment. Eligibility and procedures for 

getting funding will vary depending on the specific foundation. The best procedure is to use 

the Web site of the Foundation Center 

(http://www.foundationcenter.org) to identify a 

possible funder, then call or write to ask for information on its current funding interests and 

application procedures. The Web site allows 

visitors to search profiles of more than 65,000 

private and community foundations. The 

Foundation Center also produces a CD-ROM 

version of its database and print publications 

containing information on grants. Among the 

many foundations that have a broad interest in 

this field are the Ittleson Foundation, Inc., the 

van Ameringen Foundation, the Trull 

Foundation, the Carlisle Foundation, the Mary 

Owen Border Foundation, and the Chevron 

Corporation. 

For the most part, private funding provides an 

opportunity to enhance existing larger programs with a specific “add-on” service, such as 

employment counseling or a substance abuse 

prevention group for children of people who 

abuse substances. Programs can be significantly strengthened through the aggressive pursuit 

of available grants and by combining several 

funding opportunities. Treatment providers 

seeking funding should not overlook the possibility that major businesses operating in their 

geographic area may have charitable foundations that could be tapped for promising program initiatives. 

Attaining Equitable Allocation 

of Resources 

It is recognized that the acquisition of adequate 

program resources is both a challenging and 

essential task. Moreover, though a number of 

advances have been made in recent years in the 

treatment of people with COD, systems of care 

across the country often have not improved 

accordingly. For example, while programs are 

now working to treat COD in an integrated 

manner, mental health services and substance 

abuse treatment still are funded separately. 

This can cause programs to spend significantly 

increased amounts of time in administrative 

tasks needed to acquire funds for a client’s 

treatment through multiple streams. Also, payors in many places continue to fund treatment 

using an acute care model, even though treatment providers recognize that clients can present with long-term disorders. 

In addition to the amount of money spent on 

COD, it is important to address issues of efficiency. One study of the expenditures on COD 

found that annual spending per client with 

COD in 1997 was $5,000 to $11,000 (depending 

on the State), which is nearly twice as high as 

clients with mental disorders only and nearly 

four times as high as clients with substance use 

disorders only. 

Clients with COD compared to clients with a 

single diagnosis receive more treatment services 

of the major types—hospital inpatient, residential, and outpatient services. While clients with 

COD do not remain in the hospital as long as 

clients with mental disorders only, they do stay 

longer in residential treatment than clients with 

single diagnoses. 

Clients with COD have higher outpatient 

expenses. Those expenses are 40 to over 100 

percent higher than those of clients with mental 

disorders only, and 200 to over 300 percent 

higher than those of clients with substance use 

Keys to Successful Programming 53 
disorders only. The average amount spent for 

outpatient treatment is $2,700 to $4,600 per 

client with COD. 

In addressing COD, it is also important to look 

at medication costs when addressing the issue 

of equitable allocation of resources. In the 

three States reviewed, the estimated costs for 

those with mental disorders only and with COD 

was about $400 to $600 per person per year. 

However, clients with substance use disorders 

only generally do not get prescription medication therapy; their 

medication spending 

range was $100 to 

$200. 

When looking at the

existing allocation of 

resources for clients 

with COD and the 

demographics of

covered clients, the 

three-State estimated study found that 

they are more likely 

to be adults over the 

age of 18 and are 

more likely to be

male, but less likely 

to be minorities,

than are clients with 

single diagnoses.

They are also more 

likely to be the 

exclusive responsibility of mental 

health or substance abuse agencies rather than 

Medicaid’s total responsibility; across the three 

States, 40 to 84 percent of clients with COD 

receive services only from mental health or 

substance abuse agencies. 

The Expenditures on Treatment of CoOccurring Mental and Substance Use Disorders 

reference study involved only three States: 

Delaware, Oklahoma, and Washington. 

However, the data presented raise the issue of 

efficiency and effectiveness rather than cost. 

For those with more serious mental illness, 

strategies that are more efficient may make the 

better use of the larger amounts spent on those 

with COD, rather than creating disturbances in 

the existing system by forcing the shifting of 

resources from the treatment of those with 

either substance use disorders or mental disorders only. 

To be effective, 

resources must be 

used to implement 

the evidencebased practices 

most appropriate		

to the client population and the 

program needs. 

Ultimately, we are challenged not only to advocate on behalf of our own programs and 

clients, but for systemic change. Effective advocacy will help ensure that resources are allocated in a manner that takes appropriate cognizance of the needs of our clients and the complexity of the treatment field for clients with 

COD. However, in any advocacy caution 

against unintended consequences must be 

taken; with the de-institutionalization of 

patients hospitalized for severe and persistent 

mental illnesses, the expected reallocation of 

funds did not occur as expected. 

Any savings that could come from integrated 

treatment must not be diverted into general 

revenues. Any efficiencies that result from 

more effective treatment of those without COD, 

but with mental disorders or substance use disorders alone, should be invested into integrated 

treatment. Any transformation of the existing 

system of care that results in a decrease in 

access to substance abuse treatment for those 

without COD will only create stresses in the 

criminal justice, workplace, and child welfare 

systems. 

Integrating Research and 

Practice 

To be effective, resources must be used to 

implement the evidence-based practices most 

appropriate to the client population and the 

program needs. The importance of the transfer 

of knowledge and technology has come to be 

well understood. Conferences to explore 

“bridging the gap” between research and field 

practice are now common. 

Although not specific to COD, these efforts 

have clear implications for our attempts to 

share knowledge of what is working for clients 

54 Keys to Successful Programming 
with COD. As emphasized in the 1998 report 

by Lamb and colleagues, Bridging the Gap 

Between Research and Practice, there is a 

need for, and value in, “enhancing collaborative relationships between the drug abuse 

research community and the world of community-based treatment programs” (Lamb et al. 

1998, p. v). Brown (1998) has underscored 

the fundamental importance of making 

research relevant to practice, emphasizing the 

need for new government initiatives that focus 

on interpersonal contacts to achieve organizational change and that promote technology 

transfer as a significant area of investigation. 

Several recent government initiatives highlight this effort and are described in Changing 

the Conversation (CSAT 2000a). They include 

•Practice Improvement Collaboratives 

(SAMHSA/CSAT) 

•Clinical Trials Network Program 

(NIH/NIDA) 

•Improving the Delivery of Alcohol Treatment 

and Prevention Services (NIH/NIAAA) 

•Evidence-based Practice Centers (Agency for 

Healthcare Research and Quality) 

•The Addiction Technology Transfer Centers 

(SAMHSA/CSAT) 

•The Knowledge Application Program 

(SAMHSA/CSAT) 

•Researcher in Residence Program 

(NIH/NIAAA) 

CSAT’s Practice Improvement 

Collaboratives 

Knowledge exchange is one of the most critical elements in efforts to move best practices 

in substance abuse treatment to community 

programs working on the front lines of substance abuse interventions. Formerly known 

as the Practice/Research Collaboratives, the 

Practice Improvement Collaboratives program—designed, in part, to achieve this 

goal—supports the development of collaborations among a broad spectrum of substance 

abuse treatment organizations (including, but 

not limited to, community-based treatment 

organizations, units of government, colleges, 

universities, and other public research entities). Key objectives of the program include 

the following: 

• To develop and sustain community involvement in, and commitment to, practice 

improvement in the delivery of substance 

abuse treatment services. 

• To improve the quality of substance abuse 

treatment through the adoption of evidencebased practices in community-based treatment organizations. 

• To identify successful methods and models for 

implementing evidence-based practices in 

community-based treatment organizations. 

Workforce 

Development and 

Staff Support 

This section focuses on some key issues 

providers face in developing a workforce able 

to meet the needs of clients with COD. These 

include 

• The attitudes and values providers must have 

to work successfully with these clients 

• Essential competencies for clinicians (basic, 

intermediate, and advanced) 

• Opportunities for continuing professional 

development 

• Ways to avoid burnout and reduce 

turnover—common problems for any substance abuse treatment provider, but particularly so for those who work with clients who 

have COD 

The consensus panel underscores the importance of an investment in creating a supportive 

environment for staff that encourages professional development to include skill acquisition, 

values clarification, training, and competency 

attainment equal to an investment in new COD 

program development. An organizational commitment to both is necessary for successful 

implementation of programs. Examples of staff 

Keys to Successful Programming 55 
support may include standards of practice 

related to consistent high-quality supervision, 

favorable tuition reimbursement and release 

time policies, helpful personnel policies related 

to bolstering staff wellness practices, and incentives or rewards for work-related achievement, 

etc. Together these elements help in the creation of needed infrastructure for quality of 

service. 

Attitudes and Values 

Attitudes and values guide the way providers 

meet client needs and affect the overall treatment climate. They not only determine how the 

client is viewed by the provider (thereby generating assumptions that could either facilitate or 

deter achievement of the highest standard of 

care), but also profoundly influence how the 

client feels as he or she experiences a program. 

Attitudes and values are particularly important 

in working with clients with COD since the 

counselor is confronted with two disorders that 

require complex interventions. 

The essential attitudes and values for working 

with clients with COD shown in Figure 3-7 are 

adapted from Technical Assistance Publication 21, Addiction Counseling Competencies: 

The Knowledge, Skills, and Attitudes of 

Professional Practice (Center for Substance 

Abuse Treatment 1998a). The consensus 

panel believes these attitudes and values also 

are consistent with the attitudes and values of 

the vast majority of those who commit themselves to the challenging fields of substance 

abuse treatment and mental health services. 

Clinicians’ Competencies 

Clinicians’ competencies are the specific and 

measurable skills that counselors must possess. 

Several States, university programs, and 

expert committees have defined the key competencies for working with clients with COD. 

Typically, these competencies are developed by 

training mental health and substance abuse 

treatment counselors together, often using a 

case-based approach that allows trainees to 

experience the insights each field affords the 

other. 

One challenge of training is to include culturally sensitive methods and materials that reflect 

consideration for the varying levels of expertise 

and background of participants. The consensus 

panel recommends viewing competencies as 

basic, intermediate, and advanced to foster 

continuing professional development of all 

counselors and clinicians in the field of COD. 

This classification does not crosswalk with the 

program classification system using the same 

terminology illustrated in Figure 3-2 (p. 44) 

and is derived from various sources. Clearly, 

the sample competencies listed within each category cannot be completely separated from 

each other (e.g., competencies in the “basic” 

category may require some competency in the 

“intermediate” category). Some of the categorizations may be debatable, but the grouping 

within each category reflects, on the whole, different levels of clinician competency. 

Providers in the field face unusual challenges 

and often provide effective treatment while 

working within their established frameworks. 

In fact, research studies previously cited have 

established the effectiveness of substance 

abuse treatment approaches in working with 

persons who have low- to moderate-severity 

mental disorders. Still, the classification of 

competencies supports continued professional 

development and promotes training opportunities. 

Basic competencies 

Every substance abuse treatment and mental 

health service program should require counselors to have certain basic skills. In keeping 

with the principle that there is “no wrong 

door,” the consensus panel recommends that 

clinicians working in substance abuse treatment settings should be able to carry out the 

mental-health–related activities shown in 

Figure 3-8 (p. 58). 

56 Keys to Successful Programming 
Figure 3-7 

Essential Attitudes and Values for Clinicians Who Work With Clients Who 

Have COD 

• Desire and willingness to work with people who have COD 

• Appreciation of the complexity of COD 

• Openness to new information 

• Awareness of personal reactions and feelings 

• Recognition of the limitations of one’s own personal knowledge and expertise 

• Recognition of the value of client input into treatment goals and receptivity to client feedback 

• Patience, perseverance, and therapeutic optimism 

• Ability to employ diverse theories, concepts, models, and methods 

• Flexibility of approach 

• Cultural competence 

• Belief that all individuals have strengths and are capable of growth and development (added by consensus 

panel) 

• Recognition of the rights of clients with COD, including the right and need to understand assessment results 

and the treatment plan 

Intermediate competencies 

Intermediate competencies encompass skills in 

engaging substance abuse treatment clients with 

COD, screening, obtaining and using mental 

health assessment data, treatment planning, 

discharge planning, mental health system linkage, supporting medication, running basic mental disorder education groups, and implementing routine and emergent mental health referral procedures. In a mental health unit, mental 

health providers would exhibit similar competencies related to substance use disorders. The 

consensus panel recommends the intermediate 

level competencies shown in Figure 3-9 (p. 59), 

developed jointly by the New York State Office 

of Mental Health and the New York State 

Office of Alcohol and Substance Abuse 

Services. 

Advanced competencies 

At the advanced level, the practitioner goes 

beyond an awareness of the addiction and mental health fields as individual disciplines to a 

more sophisticated appreciation for how cooccurring disorders interact in an individual. 

This enhanced awareness leads to an improved 

ability to provide appropriate integrated treatment. Figure 3-10 (p. 60) gives examples of 

advanced skills. 

Continuing Professional 

Development 

The consensus panel is aware that many 

providers in the substance abuse treatment and 

mental health services fields have performed 

effectively the difficult task of providing services for clients with COD, until recently without much guidance from an existing body of 

knowledge or available systematic approaches. 

The landscape has changed and a solid knowledge base is now available to the counselor, 

although that knowledge typically is scattered 

through many journals and reports. This TIP 

makes an effort to integrate the available information. Counselors reading this TIP can 

review their own knowledge and determine 

what they need to continue their professional 

development. 

At the time of this writing, Arizona, 

Connecticut, Illinois, New Mexico, New York, 

Keys to Successful Programming 57 
Figure 3-8 

Examples of Basic Competencies Needed for Treatment of Persons With COD 

•Perform a basic screening to determine whether COD might exist and be able to refer the client for a formal 

diagnostic assessment by someone trained to do this. 

•Form a preliminary impression of the nature of the disorder a client may have, which can be verified by someone formally trained and licensed in mental health diagnosis. 

•Conduct a preliminary screening of whether a client poses an immediate danger to self or others and coordinate any subsequent assessment with appropriate staff and/or consultants. 

•Be able to engage the client in such a way as to enhance and facilitate future interaction. 

•De-escalate the emotional state of a client who is agitated, anxious, angry, or in another vulnerable emotional 

state. 

•Manage a crisis involving a client with COD, including a threat of suicide or harm to others. This may involve 

seeking out assistance by others trained to handle certain aspects of such crises; for example, processing commitment papers and related matters. 

•Refer a client to the appropriate mental health or substance abuse treatment facility and follow up to ensure 

the client receives needed care. 

•Coordinate care with a mental health counselor serving the same client to ensure that the interaction of the 

client’s disorders is well understood and that treatment plans are coordinated. 

and Pennsylvania have developed consensus 

guidelines that define the competencies substance abuse treatment counselors should have 

to claim expertise in this area. Others are in 

the process of identifying mechanisms for 

licensing or certifying expertise in COD. 

Counselors may check with their States’ certification bodies to determine whether training 

leading to formal credentials in counseling persons with co-occurring disorders is available. 

Appendix I identifies some resources counselors can use to enhance their professional 

knowledge and development. 

Education and training 

Discipline-specific education 

Staff education and training are fundamental 

to all substance abuse treatment programs. 

Although there have been improvements in the 

past decade, there are still very few universitybased programs that offer a formal curriculum 

on COD. Numerous observers have commented 

on the lack of adequate discipline-based training for professionals in the substance abuse 

treatment field (Brown 1996; Galanter 1989; 

Miller and Brown 1997). 

Many professional organizations are promoting 

the development of competencies and practice 

standards for intervening with substance abuse 

problems, including the Council on Addictions 

of the American Psychiatric Association; the 

American Academy of Addiction Psychiatry; 

the American Osteopathic Academy of 

Addiction Medicine; American Psychological 

Association; the American Society of Addiction 

Medicine; the Association for Medical 

Education and Research on Substance Abuse; 

the American Association of Obstetricians and 

Gynecologists; the Alcohol, Tobacco and Other 

Addictions Section of the National Association 

of Social Workers; and the International 

Nurses Society on Addictions. They are also 

specifically encouraging faculty members to 

enhance their knowledge in this area so they 

can better prepare their students to meet the 

needs of clients with COD. The consensus panel 

encourages all such organizations to identify 

standards and competencies for their member58 Keys to Successful Programming 
ship related to COD and to encourage the 

development of training for specific disciplines. 

Since the consequences of both addiction and 

mental disorders can present with physical or 

psychiatric manifestations, it is equally important for medical students, internal medicine 

and general practice residents, and general 

psychiatry residents to be educated in the 

problems of COD. Too few hours of medical 

education are devoted to the problems of 

addiction and mental disorders. Since pharmacologic therapies play a critical role in the 

treatment of those with COD, it is important to 

have adequately trained physicians who can 

manage the medication therapies for those 

clients. 

Continuing education and training 

Many substance abuse treatment counselors 

learn through continuing education and facility-sponsored training. Continuing education 

and training involves participation in a variety of courses and workshops from basic to 

advanced level offered by a number of training entities (see appendix I). The strength of 

continuing education and training courses 

and workshops is that they provide the counselor with the opportunity to review and process written material with a qualified instructor and other practitioners. 

Continuing education is useful because it can 

respond rapidly to the needs of a workforce 

that has diverse educational backgrounds and 

experience. To have practical utility, competency training must address the day-to-day issues 

that counselors face in working with clients 

with COD. The educational context must be 

rich with information, culturally sensitive, 

designed for adult students, and must include 

examples and role models. It is optimal if the 

instructors have extensive experience as practitioners in the field. Figure 3-11 (p. 61) provides 

an example description for one of many possible continuing education courses in this dynamic field. 

Continuing education is essential for effective 

provision of services to people with COD, but it 

is not sufficient in and of itself. Counselors 

must have ongoing support, supervision, and 

opportunity to practice new skills if they are to 

truly integrate COD content into their practice. 

Figure 3-9 

Six Areas of Intermediate-Level Competencies Needed for the 

Treatment of Persons With COD 

• Competency I: Integrated Diagnosis of Substance Abuse and Mental Disorders. Differential diagnosis, terminology (definitions), pharmacology, laboratory tests and physical examination, withdrawal 

symptoms, cultural factors, effects of trauma on symptoms, staff self-awareness 

• Competency II: Integrated Assessment of Treatment Needs. Severity assessment, lethality/risk, assessment of motivation/readiness for treatment, appropriateness/treatment selection 

• Competency III: Integrated Treatment Planning. Goal-setting/problemsolving, treatment planning, documentation, confidentiality,1 legal/reporting issues, documenting issues for managed care providers 

• Competency IV: Engagement and Education. Staff self-awareness, engagement, motivating, educating 

• Competency V: Early Integrated Treatment Methods. Emergency/crisis intervention, knowledge and 

access to treatment services, when and how to refer or communicate 

• Competency VI: Longer Term Integrated Treatment Methods. Group treatment, relapse prevention, 

case management, pharmacotherapy, alternatives/risk education, ethics, confidentiality,1 mental health, 

reporting requirements, family interventions 

1

Confidentiality is governed by the Federal “Confidentiality of Alcohol and Drug Abuse Patient Records” regulations (42 C.F.R. Part 2) and the Federal 

“Standards for Privacy of Individually Identifiable Health Information” (45 C.F.R. Parts 160 and 164). 

Keys to Successful Programming 59 
Figure 3-10 

Examples of Advanced Competencies in the Treatment of Clients With COD 

Source: Adapted from Minkoff 1999. 

•Use the current edition of criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (American Psychiatric Association 2000) to assess substance-related disorders and Axis I and Axis II 

mental disorders. 

•Comprehend the effects of level of functioning and degree of disability related to both substance-related 

and mental disorders, separately and combined. 

•Recognize the classes of psychotropic medications, their actions, medical risks, side effects, and possible 

interactions with other substances. 

•Use integrated models of assessment, intervention, and recovery for persons having both substance-related 

and mental disorders, as opposed to parallel treatment efforts that resist integration. 

•Apply knowledge that relapse is not considered a client failure but an opportunity for additional learning 

for all. Treat relapses seriously and explore ways of improving treatment to decrease relapse frequency 

and duration. 

•Display patience, persistence, and optimism. 

•Collaboratively develop and implement an integrated treatment plan based on thorough assessment that 

addresses both/all disorders and establishes sequenced goals based on urgent needs, considering the stage 

of recovery and level of engagement. 

•Involve the person, family members, and other supports and service providers (including peer supports 

and those in the natural support system) in establishing, monitoring, and refining the current treatment 

plan. 

•Support quality improvement efforts, including, but not limited to consumer and family satisfaction surveys, accurate reporting and use of outcome data, participation in the selection and use of quality monitoring instruments, and attention to the need for all staff to behave respectfully and collaboratively at all 

times. 

Cross-training 

Cross-training is the simultaneous provision of 

material and training to more than one discipline at a time (e.g., substance abuse and social 

work counselors; substance abuse counselors 

and corrections officers). Counselors who have 

primary expertise in either substance abuse or 

mental health will be able to work far more 

effectively with clients who have COD if they 

have some degree of cross-training in the other 

field. The consensus panel recommends that 

counselors of either field receive at least basic 

level cross-training in the other field to better 

assess, refer, understand, and work effectively 

with the large number of clients with COD. 

Cross-trained individuals who know their primary field of training well, and also have an 

appreciation for the other field, provide a richness of capacity that cannot be attained using 

any combination of personnel familiar with one 

system alone. 

When training is offered in this manner, interaction and communication between the counselors from each discipline is facilitated. This 

helps to remove barriers, increase understanding, and promote integrated work. Cross-training is particularly valuable for staff members 

who will work together in the same program. 

Consensus panel members have found crosstraining very valuable in mental health, substance abuse, and criminal justice settings. 

60 Keys to Successful Programming 
Program orientation and ongoing 

supervision 

Orientation. Staff education and training 

have two additional components: (1) a statement of program orientation that clearly presents the mission, values, and aims of service 

delivery, and (2) strong, ongoing supervision. 

The orientation can use evidence-based initiatives as well as promising practices. Successful program orientation for working with 

clients with COD will equip staff members 

with skills and decisionmaking tools that will 

enable them to provide optimal services in 

real-world environments. 

Supervision. Many agree that relational skills 

are requisite for staff working in COD programs (Gerber and Basham 1999; Martino et 

al. 2000; Miller 2000b), skills that are best 

learned though direct supervision. Active listening, interviewing techniques, the ability to 

summarize, and the capacity to provide feedback are all skills that can be best modeled by 

a supervisor. Strong, active supervision of 

ongoing cases is a key element in assisting 

staff to develop, maintain, and enhance relational skills. 

National training resources 

Training resources. Curricula and other 

forms of educational materials are available 

through Addiction Technology Transfer 

Centers (ATTCs), universities, State entities, 

and private consultants. These materials can 

help enhance the ability of substance abuse 

treatment counselors to work with clients who 

have mental disorders, as well as to enable 

mental health personnel to improve their 

efforts with persons with substance use disorders. ATTCs offer workshops, courses, and 

online remote location courses. (See appendix 

I for training sources.) 

Figure 3-11 


Treatment Planning and Documentation Issues for Mental and Substance 

Use Disorders 

Source: Supplied by consensus panelist Donna McNelis, Ph.D. 

Description 

This course provides an opportunity for participants to review the principles of collaborative treatment planning, including working from a comprehensive assessment; identifying and mutually setting long- and shortterm goals; identifying steps for accomplishing goals, the persons responsible for collaborative treatment 

planning, and a defined timeline; and reviewing and altering such plans when necessary. Progress tracking is 

reviewed, including how to write clear and concise notes, and the principles for their review. This course 

focuses on effective treatment principles and the practices of writing and reviewing plans. 

Course Objectives 

By the end of this course, participants will be able to 

• Review the principles and processes that support thorough and accurate assessment and diagnosis, including strengths-based interviewing skills and cultural diversity issues. 

• Examine each step in treatment/service planning, its rationale, and the similarities and differences in service and treatment planning. 

• Describe the importance of the person with COD having active involvement and real choice in all post-acute 

treatment planning processes (and some means for incorporating these features in acute care settings). 

• Identify means of writing brief and useful progress notes that support movement toward positive outcomes. 

• Discuss means of using progress notes with the person as a useful piece of the ongoing treatment/service 

process. 

Keys to Successful Programming 61 
Listservs and discussion lists. There are a 

number of e-mail listservs and Internet discussion groups on the topic of COD (e.g., CoOccurring Dialogues, The Dual Diagnosis 

Listserv, The Dual Diagnosis Bulletin Board, 

The Dual Diagnosis Pages: Colleagues List, 

and MIDAS: A Discussion Group). These 

online communication networks offer members the opportunity to post suggestions or 

questions to a large number of people at the 

same time. Listservs are generally geared 

more toward professionals and are more 

closely monitored. Discussion groups usually 

are open to anyone, and may not be monitored closely. (See appendix I for more 

detailed descriptions of the listservs and discussion groups mentioned above.) 

COD certification in health 

disciplines 

The disciplines of medicine and psychology 

have recognized subspecialties in COD with a 

defined process for achieving a certificate in 

this area. Figure 3-12 summarizes current 

information on certification by discipline. 

Avoiding Burnout and 

Reducing Staff Turnover 

Burnout 

Often, substance abuse and mental health 

clinicians are expected to manage growing 

and more complex caseloads. “Compassion 

fatigue” may occur when the pressures of 

work erode a counselor’s spirit and outlook 

and begin to interfere with the counselor’s 

personal life (see TIP 36, Substance Abuse 

Treatment for Persons With Child Abuse and 

Neglect Issues [CSAT 2000d], p. 64.) 

Assisting clients who have COD is difficult 

and emotionally taxing; the danger of 

burnout is considerable. It is especially 

important that program administrators maintain awareness of the problem of burnout and 

the benefits of reducing turnover. It is vital 

that staff feel that program administrators 

are interested in their well-being in order to 

sustain morale and esprit de corps. 

To lessen the possibility of burnout when 

working with a demanding caseload that 

includes clients with COD, the consensus panelists for TIP 36, Substance Abuse Treatment 

for Persons With Child Abuse and Neglect 

Issues (CSAT 2000d, p. 64) suggest that program directors and supervisors assist counselors to 

• Work within a team structure rather than in 

isolation. 

• Build in opportunities to discuss feelings and 

issues with other staff who handle similar 

cases. 

• Develop and use a healthy support network. 

• Maintain the caseload at a manageable size. 

• Incorporate time to rest and relax. 

• Separate personal and professional time. 

Most important, supervision should be supportive, providing guidance and technical 

knowledge. 

Farmer (1995) found that much of the perceived stress among substance abuse treatment counselors was attributable to workload 

factors and factors relating to management— 

for example, authoritarian and controlling 

management styles that allow staff too little 

autonomy and command over their own 

work. Performance goals should be realistic 

and clearly understood. Supervision should 

be not only a means of ensuring standards of 

practice, but also a way of encouraging and 

enabling professional growth. 

Grosch and Olsen (1994) suggest that when 

professionals begin to exhibit signs of boredom or malaise, varying the nature of the job 

is a helpful strategy. This can be accomplished via a negotiated dialog with the supervisor that is initiated by a staff member who 

requests an opportunity to try new or differing activities. 

Some programs have proactively addressed 

the issue of burnout among staff to help staff 

62 Keys to Successful Programming 
Figure 3-12 

Certification in Health Professions 

Health Profession Certification in Co-Occurring Disorders 

Physicians Physicians from any specialty, including primary care, psychiatry, and internal 

medicine can become certified by ASAM. Psychiatrists can receive added qualifications 

in Addiction Psychiatry through the formal American College of Graduate Medical 

Education Board Certification process or through the American Academy of Addiction 

Psychiatry. Osteopathic physicians from any specialty can receive addiction qualifications though the American Osteopathic Association. 

http://www.asam.org 

http://www.aaap.org 

http://www.DO-Online.org 

Psychologists Psychologists may achieve a “Certificate of Proficiency in the Treatment of Alcohol and 

Other Psychoactive Substance Use Disorders” through the American Psychological 

Association’s College of Professional Psychology. 

http://www.apa.org/education/index.aspx

Social Workers The Alcohol, Tobacco and Other Addictions Section of the National Association of Social 

Workers offers a curriculum leading to a certificate of specialty in addiction. 

http://www.naswdc.org/ 

morale, improve care, and reduce turnover in 

their program. Pavillon International, an 

addiction treatment residential program in 

North Carolina, proactively addresses 

burnout by placing high values on staff wellbeing; routinely discussing well-being issues; 

providing activities such as retreats, weekend 

activities, yoga, and other healing activities at 

the work site; and creating a network of ongoing support. 

Turnover 

The issue of staff turnover is especially important for staff working with clients with COD 

because of the limited workforce pool and the 

high investment of time and effort involved in 

developing a trained workforce. It matters, 

too, because of the crucial importance of the 

treatment relationship to successful outcomes. 

Rapid turnover disrupts the context in which 

recovery occurs. Clients in such agencies may 

become discouraged about the possibility of 

being helped by others. 

Turnover sometimes results from the unique 

professional and emotional demands of working with clients with COD. On the other hand, 

most providers in this area are unusually dedicated and find the work to be rewarding. 

Figure 3-13 (p. 64) provides some methods for 

reducing staff turnover. 

Conclusion: Workforce 

Development 

In concluding this section on workforce development, the consensus panel strongly encourages counselors to acquire the competencies 

needed to work effectively with clients who 

have COD. The difficulty of juggling a high and 

demanding workload and the desire for continued professional development should be recognized and accommodated. To the extent possiKeys to Successful Programming 63 
ble, education and training efforts should be 

customized—in terms of content, schedule, and 

location—to meet the needs of the counselors in 

the field. That is, bring the training to the 

counselor. Agency and program administrators, including both line-level and clinical 

supervisors, are urged to demonstrate support 

and encouragement for the continuing education and training of the workforce, as well as 

develop COD competencies themselves. 

Rewards can include both salary and advancement tied to the counselor’s efforts to increase 

his or her effectiveness in serving clients with 

COD, as demonstrated by job performance. 

Naturally, non-counselor clinicians working in 

primary care settings, community mental 

health centers, or private mental health offices 

also should enhance their knowledge of alcohol 

and drug use in clients with mental health 

issues. 

Figure 3-13 

Reducing Staff Turnover in Programs for Clients With COD 

To decrease staff turnover, whenever possible, programs should 

• Hire staff members who have familiarity with both substance abuse and mental disorders and have a positive regard for clients with either disorder. 

• Hire staff members who are critically minded and can think independently, but who are also willing to ask 

questions and listen, remain open to new ideas, maintain flexibility, work cooperatively, and engage in creative problemsolving. 

• Provide staff with a framework of realistic expectations for the progress of clients with COD. 

• Provide opportunities for consultation among staff members who share the same client (including medication providers). 

• Ensure that supervisory staff members are supportive and knowledgeable about issues specific to clients 

with COD. 

• Provide and support opportunities for further education and training. 

• Provide structured opportunities for staff feedback in the areas of program design and implementation. 

• Promote sophistication about, and advocacy for, COD issues among administrative staff, including both 

those in decisionmaking positions (e.g., the director and clinical director) and others (e.g., financial officers, billing personnel, and State reporting monitors). 

• Provide a desirable work environment through adequate compensation, salary incentives for COD expertise, opportunities for training and for career advancement, involvement in quality improvement or clinical 

research activities, and efforts to adjust workloads. 

64 Keys to Successful Programming 
4 Assessment 

In This 

Chapter... 

Screening and



Basic Assessment



for COD



The Assessment



Process



Overview 

This chapter consists of three parts: (1) an overview of the basic screening and assessment approach that should be a part of any program for 

clients with co-occurring disorders (COD); (2) an outline of the 12 steps 

to an ideal assessment, including some instruments that can be used in 

assessing COD; and (3) a discussion of key considerations in treatment 

matching. 

Ideally, information needs to be collected continuously, and assessments 

revised and monitored as the client moves through recovery. A comprehensive assessment as described in the main section of this chapter leads 

to improved treatment planning, and it is the intent of this chapter to 

provide a model of optimal process of evaluation for clients with COD 

and to encourage the field to move toward this ideal. Nonetheless, the 

panel recognizes that not all agencies and providers have the resources 

to conduct immediate and thorough screenings. Therefore, the chapter 

provides a description of the initial screening and the basic or minimal 

assessment of COD necessary for the initial treatment planning. 

A basic assessment covers the key information required for treatment 

matching and treatment planning. Specifically, the basic assessment 

offers a structure with which to obtain 

•Basic demographic and historical information, and identification of 

established or probable diagnoses and associated impairments 

•General strengths and problem areas 

•Stage of change or stage of treatment for both substance abuse and 

mental health problems 

•Preliminary determination of the severity of the COD as a guide to 

final level of care determination 

Note that medical issues (including physical disability and sexually transmitted diseases), cultural issues, gender-specific and sexual orientation 

issues, and legal issues always must be addressed, whether basic or more 

comprehensive assessment is performed. The consensus panel assumes 

65 
that appropriate procedures are in place to 

address these and other important issues that 

must be included in treatment planning. 

However, the focus of this chapter, in keeping 

with the purpose of this TIP, is on screening 

and assessment related to COD. 

Screening and Basic 

Assessment for COD 

This section provides an overview of the 

screening and assessment process for COD. In 

carrying out these processes, counselors should 

understand the limitations of their licensure or 

certification authority to diagnose or assess 

mental disorders. Generally, however, collecting assessment information is a legitimate and 

legal activity even for unlicensed providers, 

provided that they do not use diagnostic labels 

as conclusions or opinions about the client. 

Information gathered in this way is needed to 

ensure the client is placed in the most appropriate treatment setting (as discussed later in 

this chapter) and to assist in providing mental 

disorder care that addresses each disorder. 

In addition, there are a number of circumstances that can affect validity and test 

responses that may not be obvious to the 

beginning counselor, such as the manner in 

which instructions are given to the client, the 

setting where the screening or assessment 

takes place, privacy (or the lack thereof), and 

trust and rapport between the client and 

counselor. Throughout the process it is 

important to be sensitive to cultural context 

and to the different presentations of both 

substance use and mental disorders that may 

occur in various cultures. 

The following Advice to the Counselor section 

gives an overview of the basic “do’s and 

don’ts” for assessing for COD. Detailed discussions of these important screening/assessment and cultural issues are beyond the scope 

of this TIP. For more information on basic 

screening and assessment information, see 

chapters 4 and 5 in Evans and Sullivan 

(2001), National Institute on Drug Abuse 

(NIDA) (1994), and the National Institute on 

Alcohol Abuse and Alcoholism (NIAAA) 

(Allen and Wilson 2003). For information on 

cultural issues, see the forthcoming TIP 

Improving Cultural Competence in Substance 

Abuse Treatment (Center for Substance 

Abuse Treatment [CSAT] in development a). 

Screening 

Screening is a formal process of testing to 

determine whether a client does or does not 

warrant further attention at the current time 

in regard to a particular disorder and, in this 

context, the possibility of a co-occurring substance use or mental disorder. The screening 

process for COD seeks to answer a “yes” or 

“no” question: Does the substance abuse (or 

mental health) client being screened show 

signs of a possible mental health (or substance 

abuse) problem? Note that the screening process does not necessarily identify what kind of 

problem the person might have or how serious it might be, but determines whether or 

not further assessment is warranted. A 

screening process can be designed so that it 

can be conducted by counselors using their 

basic counseling skills. There are seldom any 

legal or professional restraints on who can be 

trained to conduct a screening. 

Screening processes always should define a 

protocol for determining which clients screen 

positive and for ensuring that those clients 

receive a thorough assessment. That is, a professionally designed screening process establishes precisely how any screening tools or 

questions are to be scored and indicates what 

constitutes scoring positive for a particular 

possible problem (often called “establishing 

cut-off scores”). Additionally, the screening 

protocol details exactly what takes place after 

a client scores in the positive range and provides the necessary standard forms to be used 

to document both the results of all later 

assessments and that each staff member has 

carried out his or her responsibilities in the 

process. 

66 Assessment 
So, what can a substance abuse treatment 

counselor do in terms of screening? All counselors can be trained to screen for COD. This 

screening often entails having a client respond 

to a specific set of questions, scoring those 

questions according to how the counselor was 

trained, and then taking the next “yes” or 

“no” step in the process depending on the 

results and the design of the screening process. In substance abuse treatment or mental 

health service settings, every counselor or 

clinician who conducts intake or assessment 

should be able to screen for the most common 

COD and know how to implement the protocol for obtaining COD assessment information 

and recommendations. For substance abuse 

treatment agencies that are instituting a mental health screening process, appendix H 

reproduces the Mental Health Screening 

Form-III (Carroll and McGinley 2001). This 

Advice to the Counselor: 

Do’s and Don’ts of Assessment for COD 

1.		Do keep in mind that assessment is about getting to know a person with complex and individual needs. Do not rely on tools alone for a comprehensive assessment. 

2.		Do always make every effort to contact all involved parties, including family members, persons 

who have treated the client previously, other mental health and substance abuse treatment 

providers, friends, significant others, probation officers as quickly as possible in the assessment 

process. (These other sources of information will henceforth be referred to as collaterals.) 

3.		Don’t allow preconceptions about addiction to interfere with learning about what the client 

really needs (e.g., “All mental symptoms tend to be caused by addiction unless proven otherwise”). Co-occurring disorders are as likely to be underrecognized as overrecognized. Assume 

initially that an established diagnosis and treatment regime for mental illness is correct, and 

advise clients to continue with those recommendations until careful reevaluation has taken 

place. 

4.		Do become familiar with the diagnostic criteria for common mental disorders, including personality disorders, and with the names and indications of common psychiatric medications. Also 

become familiar with the criteria in your own State for determining who is a mental health priority client. Know the process for referring clients for mental health case management services 

or for collaborating with mental health treatment providers. 

5.		Don’t assume that there is one correct treatment approach or program for any type of COD. The 

purpose of assessment is to collect information about multiple variables that will permit individualized treatment matching. It is particularly important to assess stage of change for each problem and the client’s level of ability to follow treatment recommendations. 

6.		Do become familiar with the specific role that your program or setting plays in delivering services related to COD in the wider context of the system of care. This allows you to have a clearer 

idea of what clients your program will best serve and helps you to facilitate access to other settings for clients who might be better served elsewhere. 

7.		Don’t be afraid to admit when you don’t know, either to the client or yourself. If you do not 

understand what is going on with a client, acknowledge that to the client, indicate that you will 

work with the client to find the answers, and then ask for help. Identify at least one supervisor 

who is knowledgeable about COD as a resource for asking questions. 

8. Most important, do remember that empathy and hope are the most valuable components of 

your work with a client. When in doubt about how to manage a client with COD, stay connected, be empathic and hopeful, and work with the client and the treatment team to try to figure 

out the best approach over time. 

Assessment 67 
instrument is intended for use as a rough 

screening device for clients seeking admission 

to substance abuse treatment programs. (Note 

that while the consensus panel believes that 

this instrument is useful, it has received limited validation [Carroll and McGinley 2001].) 

Basic Assessment 

While both screening and assessment are ways 

of gathering information about the client in 

order to better treat him, assessment differs 

from screening in the following way: 

•Screening is a process for evaluating the possible presence of a particular problem. 

•Assessment is a process for defining the 

nature of that problem and developing specific treatment recommendations for addressing 

the problem. 

A basic assessment consists of gathering key 

information and engaging in a process with 

the client that enables the counselor to understand the client’s readiness for change, problem areas, COD diagnosis(es), disabilities, 

and strengths. An assessment typically 

involves a clinical examination of the functioning and well-being of the client and 

includes a number of tests and written and 

oral exercises. The COD diagnosis is established by referral to a psychiatrist, clinical 

psychologist, or other qualified healthcare 

professional. Assessment of the client with 

COD is an ongoing process that should be 

repeated over time to capture the changing 

nature of the client’s status. Intake information consists of 

1. Background—family, trauma history, history of domestic violence (either as a batterer 

or as a battered person), marital status, 

legal involvement and financial situation, 

health, education, housing status, strengths 

and resources, and employment 

2. Substance use—age of first use, primary 

drugs used (including alcohol, patterns of 

drug use, and treatment episodes), and family history of substance use problems 

3. Mental health problems—family history of 

mental health problems, client history of 

mental health problems including diagnosis, 

hospitalization and other treatment, current 

symptoms and mental status, medications, 

and medication adherence 

In addition, the basic information can be augmented by some objective measurement, such 

as that provided in the University of Rhode 

Island Change Assessment Scale (URICA) 

(McConnaughy et al. 1983), Addiction Severity 

Index (ASI) (McLellan et al. 1992), the Mental 

Health Screening Form-III (Carroll and 

McGinley 2001), and the Symptom Distress 

Scale (SDS) (McCorkle and Young 1978) (see 

appendices G and H for further information on 

selected instruments). It is essential for treatment planning that the counselor organize the 

collected information in a way that helps identify established mental disorder diagnoses and 

current treatment. The text box on page 71 

highlights the role of instruments in the assessment process. 

Careful attention to the characteristics of past 

episodes of substance abuse and abstinence 

with regard to mental health symptoms, 

impairments, diagnoses, and treatments can 

illuminate the role of substance abuse in 

maintaining, worsening, and/or interfering 

with the treatment of any mental disorder. 

Understanding a client’s mental health symptoms and impairments that persist during 

periods of abstinence of 30 days or more can 

be useful, particularly in understanding what 

the client copes with even when the acute 

effects of substance use are not present. For 

any period of abstinence that lasts a month or 

longer, the counselor can ask the client about 

mental health treatment and/or substance 

abuse treatment—what seemed to work, what 

did the client like or dislike, and why? On the 

other hand, if mental health symptoms (even 

suicidality or hallucinations) resolve in less 

than 30 days with abstinence from substances, then these symptoms are most likely 

substance induced and the best treatment is 

maintaining abstinence from substances. 

The counselor also can ask what the mental 

health “ups and downs” are like for the 

client. That is, what is it like for the client 

68 Assessment 
when he or she gets worse (or “destabilizes”)? 

What—in detail—has happened in the past? 

And, what about getting better (“stabilizing”)—how does the client usually experience 

that? Clinician and client together should try 

to understand the specific effects that substances have had on that individual’s mental 

health symptoms, including the possible triggering of psychiatric symptoms by substance 

use. Clinicians also should attempt to document the diagnosis of a mental disorder, when 

it has been established, and determine diagnosis through referral when it has not been 

established. The consensus panel notes that 

many, if not most, individuals with COD have 

well-established diagnoses when they enter 

substance abuse treatment and encourages 

counselors to find out about any known diagnoses. 

Treatment Planning 

A comprehensive assessment serves as the basis 

for an individualized treatment plan. 

Appropriate treatment plans and treatment 

interventions can be quite complex, depending 

on what might be discovered in each domain. 

This leads to another fundamental principle: 

•There is no single, correct intervention or 

program for individuals with COD. Rather, 

the appropriate treatment plan must be 

matched to individual needs according to 

these multiple considerations. 

The following three cases illustrate how the 

above factors help to generate an integrated 

treatment plan that is appropriate to the needs 

and situation of a particular client. 

Case 1: Maria M. 

The client is a 38-year-old Hispanic/Latina 

woman who is the mother of two teenagers. 

Maria M. presents with an 11-year history 

of cocaine dependence, a 2-year history of 

opioid dependence, and a history of trauma 

related to a longstanding abusive relationship (now over for 6 years). She is not in an 

intimate relationship at present and there is 

no current indication that she is at risk for 

either violence or self-harm. She also has 

persistent major depression and panic treated with antidepressants. She is very motivated to receive treatment. 

• Ideal Integrated Treatment Plan: The 

plan for Maria M. might include medication-assisted treatment (e.g., methadone or 

buprenorphine), continued antidepressant 

medication, 12-Step program attendance, 

and other recovery group support for 

cocaine dependence. She also could be 

The Role of Assessment Tools 

A frequent question asked by clinicians is 

•What is the best (most valuable) assessment tool for COD? 

The answer is 

•There is no single gold standard assessment tool for COD. Many traditional clinical tools have a narrow focus 

on a specific problem, such as the Beck Depression Inventory (BDI) (Beck and Steer 1987), a list of 21 questions about mood and other symptoms of feeling depressed. Other tools have a broader focus and serve to 

organize a range of information so that the collection of such information is done in a standard, regular way 

by all counselors. The ASI, which is not a comprehensive assessment tool but a measure of addiction severity 

in multiple problem domains, is an example of this type of tool (McLellan et al. 1992). Not only does a tool 

such as the ASI help a counselor, through repetition, become adept at collecting the information, it also helps 

the counselor refine his or her sense of similarities and differences among clients. A standard mental status 

examination can serve a similar function for collecting information on current mental health symptoms. 

Despite the fact that there are some very good tools, no one tool is the equivalent of a comprehensive clinical 

assessment. 

Assessment 69 
referred to a group for trauma survivors 

that is designed specifically to help reduce 

symptoms of trauma and resolve long-term 

issues. 

Individual, group, and family interventions 

could be coordinated by the primary counselor from opioid maintenance treatment. 

The focus of these interventions might be on 

relapse prevention skills, taking medication 

as prescribed, and identifying and managing 

trauma-related symptoms without using. An 

appropriate long-term goal would be to establish abstinence and engage Maria in longerterm psychotherapeutic interventions to 

reduce trauma symptoms and help resolve 

trauma issues. On the other hand, if a local 

mental health center had a psychiatrist 

trained and licensed to provide Suboxone 

(the combination of buprenorphine and 

nalaxone), her case could be based in the 

mental health center. 

Case 2: George T. 

The client is a 34-year-old married, 

employed African-American man with 

cocaine dependence, alcohol abuse, and 

bipolar disorder (stabilized on lithium) who 

is mandated to cocaine treatment by his 

employer due to a failed drug test. George 

T. and his family acknowledge that he needs 

help not to use cocaine but do not agree that 

alcohol is a significant problem (nor does his 

employer). He complains that his mood 

swings intensify when he is using cocaine. 

• Ideal Integrated Treatment Plan: The 

ideal plan for this man might include participation in outpatient addiction treatment, 

plus continued provision of mood-stabilizing medication. In addition, he should be 

encouraged to attend a recovery group such 

as Cocaine Anonymous or Narcotics 

Anonymous. The addiction counselor would 

provide individual, group, and family interventions. The focus might be on gaining the 

skills and strategies required to handle 

cocaine cravings and to maintain abstinence 

from cocaine, as well as the skills needed to 

manage mood swings without using substances. Motivational counseling regarding 

alcohol and assistance in maintaining medication (lithium) adherence also could be 

part of the plan. 

Case 3: Jane B. 

The client is a 28-year-old single Caucasian 

female with a diagnosis of paranoid 

schizophrenia, alcohol dependence, crack 

cocaine dependence, and a history of multiple episodes of sexual victimization. Jane B. 

is homeless (living in a shelter), actively psychotic, and refuses to admit to a drug or 

alcohol problem. She has made frequent visits to the local emergency room for both 

mental health and medical complaints, but 

refuses any followup treatment. Her main 

requests are for money and food, not treatment. Jane has been offered involvement in 

a housing program that does not require 

treatment engagement or sobriety but has 

refused due to paranoia regarding working 

with staff to help her in this setting. Jane B. 

refuses all medication due to her paranoia, 

but does not appear to be acutely dangerous 

to herself or others. 

• Ideal Integrated Treatment Plan: The 

plan for Jane B. might include an integrated case management team that is either 

based in the shelter or in a mental health 

service setting. The team would apply a 

range of engagement, motivational, and 

positive behavioral change strategies aimed 

at slowly developing a trusting relationship 

with this woman. Engagement would be 

promoted by providing assistance to Jane 

B. in obtaining food and disability benefits, 

and using those connections to help her 

engage gradually in treatment for either 

mental disorders or addiction—possibly by 

an initial offer of help in obtaining safe and 

stable housing. Peer support from other 

70 Assessment 
women also might be of value in promoting pe

her sense of safety and engagement. pe

All of these cases are appropriate examples of 

integrated treatment. The purpose of the 

assessment process is to develop a method for 

gathering information in an organized manner 

that allows the clinician to develop an appropriate treatment plan or recommendation. The 

remainder of this chapter will discuss how this 

assessment process might occur, and how the 

information gathered leads to a rational process of treatment planning. In Step 12 of the 

assessment process, readers will find an 

expanded treatment plan for the three clients 

discussed above. 

The Assessment 

Process 

This chapter is organized around 12 specific 

steps in the assessment process. Through these 

steps, the counselor seeks to accomplish the following aims: 

•To obtain a more detailed chronological history of past mental symptoms, diagnosis, 

treatment, and impairment, particularly 

before the onset of substance abuse, and 

during periods of extended abstinence. 

•To obtain a more detailed description of 

current strengths, supports, limitations, 

skill deficits, and cultural barriers related 

to following the recommended treatment 

regimen for any disorder or problem. 

•To determine stage of change for each problem, and identify external contingencies 

that might help to promote treatment 

adherence. 

Note that although the steps appear sequential, 

in fact some of them could occur simultaneously or in a different order, depending on the situation. It is particularly important to identify 

and attend to any acute safety needs, which 

often have to be addressed before a more comprehensive assessment process can occur. 

Sometimes, however, components of the assessment process are essential to address the 

client’s specific safety needs. For example, if a 

rson is homeless, more information on that 

rson’s mental status, resources, and overall 

situation is required to address that priority 

appropriately. Finally, it must be recognized 

that while the assessment seeks to identify individual needs and vulnerabilities as quickly as 

possible to initiate appropriate treatment, 

assessment is an ongoing process: As treatment 

proceeds and as other changes occur in the 

client’s life and mental status, counselors must 

actively seek current information rather than 

proceed on assumptions that might be no 

longer valid. 

In the following discussion, validated assessment tools that are available to assist in this 

process are discussed with regard to their 

utility for counselors. There are a number of 

tools that are required by various States for 

use in their addiction systems (e.g., ASI 

[McLellan et al. 1992], American Society of 

Addiction Medicine (ASAM) Patient 

Placement Criteria [ASAM PPC-2R]). 

Particular attention will be given to the role 

of these tools in the COD assessment process, 

suggesting strategies to reduce duplication of 

effort where possible. It is beyond the scope 

of this TIP to provide detailed instructions 

for administering the tools mentioned in this 

TIP (with the exceptions of the Mental Health 

Screening Form-III [MHSF-III] and the 

Simple Screening Instrument for Substance 

Abuse [SSI-SA] in appendix H). Basic information about each instrument is given in 

appendix G, and readers can obtain more 

detailed information regarding administration 

and interpretation from the sources given for 

obtaining these instruments. 

As a final point, this discussion primarily is 

directed toward substance abuse treatment 

clinicians working in substance abuse treatment settings, though many of the steps apply 

equally well to mental health clinicians in 

mental health settings. At certain key points 

in the discussion, particular information relevant to mental health clinicians is identified 

and described. 

Assessment 71 
Assessment Step 1: Engage 

the Client 

The first step in the assessment process is to 

engage the client in an empathic, welcoming 

manner and build a rapport to facilitate open 

disclosure of information regarding mental 

health problems, substance use disorders, 

and related issues. The aim is to create a safe 

and nonjudgmental environment in which 

sensitive personal issues may be discussed. 

Counselors should recognize that cultural 

issues, including the use of the client’s preferred language, play a role in creating a 

sense of safety and promote accurate understanding of the client’s situation and options. 

Such issues therefore must be addressed sensitively at the outset and throughout the 

assessment process. 

The consensus panel identified five key concepts that underlie effective engagement during the initial clinical contact: universal 

access (“no wrong door”), empathic detachment, person-centered assessment, cultural 

sensitivity, and trauma sensitivity. All staff, 

as well as substance abuse treatment and 

mental health clinicians, in any service setting 

need to develop competency in engaging and 

welcoming individuals with COD. It is also 

important to note that while engagement is 

presented here as the first necessary step for 

assessment to take place, in a larger sense 

engagement represents an ongoing concern of 

the counselor—to understand the client’s 

experience and to keep him or her positive 

and engaged relative to the prospect of better 

health and recovery. 

No wrong door 

“No wrong door” refers to formal recognition 

by a service system that individuals with COD 

may enter a range of community service sites; 

that they are a high priority for engagement 

in treatment; and that proactive efforts are 

necessary to welcome them into treatment and 

prevent them from falling through the cracks. 

Substance abuse and mental health counselors are encouraged to identify individuals 

with COD, welcome them into the service system, and initiate proactive efforts to help 

them access appropriate treatment in the system, regardless of their initial site of presentation. The recommended attitude is as follows: The purpose of this assessment is not 

just to determine whether the client fits in my 

program, but to help the client figure out 

where he or she fits in the system of care, and 

to help him or her get there. 

Twelve Steps in the Assessment Process 

Step 1: Engage the client 

Step 2: Identify and contact collaterals (family, friends, other providers) to gather additional information 

Step 3: Screen for and detect COD 

Step 4: Determine quadrant and locus of responsibility 

Step 5: Determine level of care 

Step 6: Determine diagnosis 

Step 7: Determine disability and functional impairment 

Step 8: Identify strengths and supports 

Step 9: Identify cultural and linguistic needs and supports 

Step 10: Identify problem domains 

Step 11: Determine stage of change 

Step 12: Plan treatment 

72 Assessment 
Empathic detachment 

Empathic detachment requires the assessing 

clinician to 

•Acknowledge that the clinician and client are 

working together to make decisions to support the client’s best interest 

•Recognize that the clinician cannot transform 

the client into a different person, but can 

only support change that he or she is already 

making 

•Maintain empathic connection even if the 

client does not seem to fit into the clinician’s expectations, treatment categories, or 

preferred methods of working 

In the past, the attitude was that the client with 

COD was the exception. Today, clinicians 

should be prepared to demonstrate responsiveness to the requirements clients with COD present. Counselors should be careful not to label 

mental health symptoms immediately as caused 

by addiction, but instead should be comfortable with the strong possibility that a mentalhealth condition may be present independently 

and encourage disclosure of information that 

will help clarify the meaning of any COD for 

that client. 

Person-centered assessment 

Person-centered assessment emphasizes that 

the focus of initial contact is not on filling out a 

form or answering several questions or on 

establishing program fit, but rather on finding 

out what the client wants, in terms of his or her 

perception of the problem, what he or she 

wants to change, and how he or she thinks that 

change will occur. Mee-Lee (1998) has developed a useful guide that illustrates the types of 

questions that might be asked in a person-centered assessment in an addiction setting (see 

Figure 4-1, p. 74). (It should be noted, however, that this is not a validated tool.) While each 

step in this decision tree leads to the next, the 

final step can lead back to a previous step, 

depending on the client’s progress in treatment. 

Answers to some of these important questions 

inevitably will change over time. As the 

answers change, adjustments in treatment 

strategies may be appropriate to help the client 

continue to engage in the treatment process. 

Sensitivity to culture, gender, 

and sexual orientation 

An important component of a person-centered 

assessment is the continual recognition that culture plays a significant role in determining the 

client’s view of the problem and the treatment. 

(For a comprehensive discussion of culturally 

sensitive assessment strategies in addiction settings, see the forthcoming TIP Improving 

Cultural Competence in Substance Abuse 

Treatment [CSAT in development a]). With 

regard to COD, clinicians must remember that 

ethnic cultures may differ significantly in their 

approach to substance use disorders and mental disorders, and that this may affect how the 

client presents. In addition, clients may participate in treatment cultures (12-Step recovery, 

Dual Recovery Self-Help, psychiatric rehabilitation) that also may affect how they view treatment. Cultural sensitivity also requires recognition of one’s own cultural perspective and a 

genuine spirit of inquiry into how cultural factors influence the client’s request for help. (See 

also chapter 2 for a discussion of culturally 

competent treatment.) 

During the assessment process, it is important 

to ascertain the individual’s sexual orientation as part of the counselor’s appreciation 

for the client’s personal identity, living situation, and relationships. Counselors also 

should be aware that women often have family-related and other concerns that must be 

addressed to engage them in treatment, such 

as the need for child care. See chapter 7 of 

this TIP for a more extended consideration of 

women with COD as a population with specific needs. More information about women’s 

issues is provided in the forthcoming TIP 

Substance Abuse Treatment: Addressing the 

Specific Needs of Women (CSAT in development b). 

Assessment 73 
Figure 4-1 

Assessment Considerations 

Engagement: 

•What does the client want? 

•What is the treatment contract? 

•What are the immediate needs? 

•What are the multiaxial DSM-IV diagnoses?



Multidimensional severity/level of functioning profile:



•Identify which assessment dimensions are most severe to determine treatment priorities.



•Choose a specific priority for each medium/severe dimension.



What specific services are needed to address these priorities?



What “dose” or intensity of services is needed?



Where can these services be provided in the least intensive, but safe, level of care or site of care?



How will outcomes be measured?



What is the progress of the treatment plan and placement decision?



Source: Adapted from Mee-Lee 1998.



Trauma sensitivity 

The high prevalence of trauma in individuals 

with COD requires that the clinician consider 

the possibility of a trauma history even before 

the assessment begins. Trauma may include 

early childhood physical, sexual, or emotional 

abuse; experiences of rape or interpersonal 

violence as an adult; and traumatic experiences associated with political oppression, as 

might be the case in refugee or other immigrant populations. This pre-interview consideration means that the approach to the client 

must be sensitive to the possibility that the 

client has suffered previous traumatic experiences that may interfere with his or her ability to be trusting of the counselor. Clinicians 

who observe guardedness on the part of the 

client should consider the possibility of trauma and try to promote safety in the interview 

through providing support and gentleness, 

rather than trying to “break through” evasiveness that erroneously might look like 

resistance or denial. All questioning should 

avoid “retraumatizing” the client—see section 

on trauma screening later in this chapter and, 

for additional details, see the forthcoming 

TIP Substance Abuse Treatment and Trauma 

(CSAT in development d). 

Assessment Step 2: Identify 

and Contact Collaterals 

(Family, Friends, Other 

Providers) To Gather 

Additional Information 

Clients presenting for substance abuse treatment, particularly those who have current or 

past mental health symptoms, may be unable 

or unwilling to report past or present circumstances accurately. For this reason, it is recommended that all assessments include routine 

procedures for identifying and contacting any 

family and other collaterals who may have useful information to provide. Information from 

collaterals is valuable as a supplement to the 

client’s own report in all of the assessment steps 

74 Assessment 
listed in the remainder of this chapter. It is 

valuable particularly in evaluating the nature 

and severity of mental health symptoms when 

the client may be so impaired that he or she is 

unable to provide that information accurately. 

Note, however, that the process of seeking such 

information must be carried out strictly in 

accordance with applicable guidelines and laws 

regarding confidentiality1 and with the client’s 

permission. 

Assessment Step 3: Screen for 

and Detect Co-Occurring 

Disorders 

Because of the high prevalence of co-occurring 

mental disorders in substance abuse treatment 

settings, and because treatment outcomes for 

individuals with multiple problems improve if 

each problem is addressed specifically, the consensus panel recommends that 

•All individuals presenting for substance abuse 

treatment should be screened routinely for 

co-occurring mental disorders. 

•All individuals presenting for treatment for a 

mental disorder should be screened routinely 

for any substance use disorder. 

The content of the screening will vary upon the 

setting. Substance abuse screening in mental 

health settings should 

•Screen for acute safety risk related to serious 

intoxication or withdrawal 

•Screen for past and present substance use, 

substance related problems, and substancerelated disorders 

Mental health screening has four major components in substance abuse treatment settings: 

•Screen for acute safety risk: suicide, violence, 

inability to care for oneself, HIV and hepatitis C virus risky behaviors, and danger of 

physical or sexual victimization 

•Screen for past and present mental health 

symptoms and disorders 

•Screen for cognitive and learning deficits 

• Regardless of the setting, all clients should be 

screened for past and present victimization 

and trauma. 

Safety screening 

Safety screening requires that early in the 

interview the clinician specifically ask the client 

if he or she has any immediate impulse to 

engage in violent or self-injurious behavior, or 

if the client is in any immediate danger from 

others. These questions should be asked directly of the client and of anyone else who is providing information. If the answer is yes, the 

clinician should obtain more detailed information about the nature and severity of the danger, the client’s ability to avoid the danger, the 

immediacy of the danger, what the client needs 

to do to be safe and feel safe, and any other 

information relevant to safety. Additional 

information can be gathered depending on the 

counselor/staff training for crisis/emergency situations and the interventions appropriate to 

the treatment provider’s particular setting and 

circumstances. Once this information is gathered, if it appears that the client is at some 

immediate risk, the clinician should arrange 

for a more in-depth risk assessment by a mental-health–trained clinician, and the client 

should not be left alone or unsupervised. 

A variety of tools are available for use in safety 

screening: 

• ASAM PPC-2R identifies considerations for 

immediate risk assessment and recommends 

follow up procedures (ASAM 2001). 

• ASI (McLellan et al. 1992) and Global 

Appraisal of Individual Needs (GAIN) 

(Dennis 1998) also include some safety 

screening questions. 

• Some systems use LOCUS (American 

Association of Community Psychiatrists 

[AACP] 2000a) as the tool to determine level 

of care for both mental disorders and addiction. One dimension of LOCUS specifically 

provides guides for scoring severity of risk of 

1

Confidentiality is governed by the Federal “Confidentiality of Alcohol and Drug Abuse Patient Records” regulations (42 C.F.R. 

Part 2) and the Federal “Standards for Privacy of Individually Identifiable Health Information” (45 C.F.R. Parts 160 and 164). 

Assessment 75 
harm. See Potential Risk of Harm on 

page 77. 

None of these tools is definitive for safety 

screening. Clinicians and programs should use 

one of these tools only as a starting point, and 

then elaborate more detailed questions to get 

all relevant information. 

Clinicians should not underestimate risk 

because the client is using substances actively. 

For example, although people who are intoxi­


cated might only seem to be making threats of 


self-harm (e.g., “I’m just going to go home 


and blow my head off if nobody around here 

can help me”), all statements about harming 


oneself or others must be taken seriously. 

Individuals who have suicidal or aggressive 

impulses when intoxicated may act on those 


impulses; remember, alcohol and drug abuse 


are among the highest predictors of danger­


ousness to self or others—even without any 


co-occurring mental disorder. Determining 


which intoxicated suicidal client is “serious” 


and which one is not requires a skilled mental 

health assessment, plus information from collaterals who know the client best. (See chapter 8 and appendix D of this TIP for a more 

detailed discussion of suicidality.) In addition, it is important to remember that the vast 

majority of people who are abusing or depen­


dent on substances will experience at least 


transient symptoms of depression, anxiety, 

and other mental symptoms. Moreover, it 

may not be possible, even with a skilled clinician, to determine whether an intoxicated suicidal patient is making a serious threat of self

harm; however, safety is a critical and 

paramount concern. A more detailed discussion of each symptom subgroup is provided in 

appendix D. Safety screening conducted in

mental health settings is highlighted in the

text box below. 

Screening for past and present mental disorders 

Screening for past and present mental disor­


ders has three goals: 


1. To understand a client’s history and, if the 


history is positive for a mental disorder, to 


alert the counselor and treatment team to 


the types of symptoms that might reappear


so that the counselor, client, and staff can 


be vigilant about the emergence of any such

symptoms.


2. To identify clients who might have a current 

mental disorder and need both an assessment to determine the nature of the disorder and an evaluation to plan for its treatment.

Safety Screening in Mental Health Settings 

Evaluating safety considerations in mental health settings involves direct questioning of client and collaterals 

regarding current substance use and/or recent discontinuation of heavy use, along with past and present experiences of withdrawal. If clients obviously are intoxicated, they need to be treated with empathy and firmness, 

and provision needs to be made for their physical safety. If clients report that they are experiencing withdrawal, or appear to be exhibiting signs of withdrawal, use of formal withdrawal scales can help even inexperienced 

clinicians to gather information from which medically trained personnel can determine whether medical intervention is required. Such tools include the Clinical Institute Withdrawal Assessment (CIWA-Ar) (Sullivan et al. 

1989) for alcohol withdrawal and the Clinical Institute Narcotic Assessment (CINA) (Zilm and Sellers 1978) for 

opioid withdrawal. 

Mental health clinicians need to be aware that not all drugs have a physiological withdrawal associated with 

them, and it should not be assumed that withdrawal from any drug of abuse will require medical intervention. 

Only in the case of alcohol, opioids, sedative-hypnotics, or benzodiazepines is medical intervention likely to be 

required due to the pharmacological properties of the substance. 

76 Assessment 
Potential Risk of Harm 


• Risk of Harm: This dimension of the assessment considers a person’s potential to cause significant harm to self or 

others. While this may most frequently be due to suicidal or homicidal thoughts or intentions, in many cases unintentional harm may result from misinterpretations of reality, from inability to care adequately for oneself, or from 

altered states of consciousness due to use of intoxicating substances. For the purpose of evaluation in this parameter, 

deficits in ability to care for oneself are considered only in the context of their potential to cause harm. Likewise, only 

behaviors associated with substance use are used to rate risk of harm, not the substance use itself. In addition to 

direct evidence of potentially dangerous behavior from interview and observation, other factors may be considered in 

determining the likelihood of such behavior such as past history of dangerous behaviors, ability to contract for safety, 

and availability of means. When considering historical information, recent patterns of behavior should take precedence over patterns reported from the remote past. Risk of harm may be rated according to the following criteria: 

Minimal risk of harm: 

(a) No indication of suicidal or homicidal thoughts or impulses, no history of suicidal or homicidal ideation, and no 

indication of significant distress. 

(b) Clear ability to care for self now and in the past. 

Low risk of harm: 

(a) No current suicidal or homicidal ideation, plan, intentions or serious distress, but may have had transient or passive thoughts recently or in the past. 

(b) Substance use without significant episodes of potentially harmful behaviors. 

(c) Periods in the past of self-neglect without current evidence of such behavior. 

Moderate risk of harm: 

(a) Significant current suicidal or homicidal ideation without intent or conscious plan and without past history. 

(b) No active suicidal/homicidal ideation, but extreme distress and/or a history of suicidal/homicidal behavior exists. 

(c) History of chronic impulsive suicidal/homicidal behavior or threats and current expressions do not represent significant change from baseline. 

(d) Binge or excessive use of substances resulting in potentially harmful behaviors without current involvement in



such behavior.
 


(e) Some evidence of self neglect and/or compromise in ability to care for oneself in current environment. 

Serious risk of harm: 

(a) Current suicidal or homicidal ideation with expressed intentions and/or past history of carrying out such behavior 

but without means for carrying out the behavior, or with some expressed inability or aversion to doing so, or with 

ability to contract for safety. 

(b) History of chronic impulsive suicidal/homicidal behavior or threats with current expressions or behavior representing a significant elevation from baseline. 

(c) Recent pattern of excessive substance use resulting in disinhibition and clearly harmful behaviors with no demonstrated ability to abstain from use. 

(d) Clear compromise of ability to care adequately for oneself or to be aware adequately of environment.



Extreme risk of harm:



(a) Current suicidal or homicidal behavior or such intentions with a plan and available means to carry out this 

behavior without expressed ambivalence or significant barriers to doing so; or with a history of serious past 

attempts which are not of a chronic, impulsive, or consistent nature; or in presence of command hallucinations or 

delusions which threaten to override usual impulse control. 

(b) Repeated episodes of violence toward self or others, or other behaviors resulting in harm while under the influence of intoxicating substances with pattern of nearly continuous and uncontrolled use. 

(c) Extreme compromise of ability to care for oneself or to monitor adequately the environment with evidence of deterioration in physical condition or injury related to these deficits. 

Source: AACP 2000a. 

Assessment 77 
3.	 For clients with a current COD, to determine the nature of the symptoms that might

wax and wane to help the client monitor the

symptoms, especially how the symptoms

improve or worsen in response to medications, “slips” (i.e., substance use), and

treatment interventions. For example,

clients often need help seeing that the treatment goal of avoiding isolation improves

their mood—that when they call their sponsor and go to a meeting they break the

vicious cycle of depressed mood, seclusion,

dwelling on oneself and one’s mood,

increased depression, greater isolation, and

so on.

A number of screening, assessment, and

treatment planning tools are available to

assist the substance abuse treatment team.

For assessment of specific disorders

and/or for differential diagnosis and treatment planning, there are literally hundreds of assessment and treatment planning tools. NIAAA operates a web­based

service that provides quick information

about alcoholism treatment assessment

instruments and immediate online access

to most of them, and the service is updated continually with new information and

assessment instruments NIDA has a publication from a decade ago (Rounsaville et

al. 1993) that provides broad background

information on assessment issues pertinent

to COD and specific information about

numerous mental health, treatment planning, and substance abuse tools. Of

course, NIDA continues to explore issues

related to screening and assessment. The

mental health field contains a vast array

of screening and assessment devices, as

well as subfields devoted primarily to the

study and development of evaluative

methods. Almost all Substance Abuse and

Mental Health Services Administration

TIPs, which are available online

(www.kap.samhsa.gov), have a section on

assessment, many have appendices with

wholly reproduced assessment tools or

information about locating such tools, and

drawal from many substances. Even with

well­tested tools, it can be difficult to distinTIPs 31, 16, 13, 11, 10, 9, 7, and 6 are centered specifically on assessment issues.

Advanced assessment techniques include

assessment instruments for general and specific purposes and advanced guides to differential diagnosis. Most high­power assessment

techniques center on a specific type of problem or set of symptoms, such as the BDI­II

(Beck et al. 1996), the Beck Anxiety

Inventory (BAI) (Beck et al. 1988), or the

Hamilton Anxiety Scale (Hamilton 1959) or

the Hamilton Rating Scale for Depression

(Hedlung and Vieweg 1979). There are highpower broad assessment measures such as the

Minnesota Multiphasic Personality Inventory2 (MMPI­2) (Butcher et al. 2001). However,

such assessment devices typically are lengthy

(the MMPI is more than 500 items), often

require specific doctoral training to use, and

can be difficult to adapt properly for some

substance abuse treatment settings. 

For both clinical and research activities,

there are a number of well­known and widely

used guides to the differential diagnostic process in the mental health field, such as the

Structured Clinical Interview for Diagnosis

(SCID). Again, the SCIDs involve considerable time and training, with a separate SCID

for Axis I, Axis II, and dissociative disorders.

Other broad high­power diagnostic tools are

the Diagnostic Interview Schedule (DIS) and

the Psychiatric Research Interview for

Substance and Mental Disorders (PRISM),

but these methods can require 1 to 3 hours

and extensive training. These tools generally

provide information beyond the requirements

of most substance abuse treatment programs.

When using any of the wide array of tools

that detect symptoms of mental disorders,

counselors should bear in mind that symptoms of mental disorder can be mimicked by

substances. For example, hallucinogens may

produce symptoms that resemble psychosis,

and depression commonly occurs during with78 Assessment
guish between a mental disorder and a substance-related disorder without additional 

information such as the history and chronology of symptoms. In addition to interpreting 

the results of such instruments in the broader 

context of what is known about the client’s 

history, counselors also are reminded that 

retesting often is important, particularly to 

confirm diagnostic conclusions for clients who 

have used substances. 

The section below briefly highlights some 

available instruments available for mental 

health screening. 

Mental Health Screening 

Form-III 

The Mental Health Screening Form-III 

(MHSF-III) has only 18 simple questions and 

is designed to screen for present or past 

symptoms of most of the main mental disorders (Carroll and McGinley 2001). It is available to the public at no charge from the 

Project Return Foundation, Inc. and it is 

reproduced in its entirety in appendix H, 

along with instructions for its use and contact 

information (a Spanish form and instructions 

can be downloaded). The MHSF-III was 

developed within a substance abuse treatment 

setting and it has face validity—that is, if a 

knowledgeable diagnostician reads each item, 

it seems clear that a “yes” answer to that item 

would warrant further evaluation of the client 

for the mental disorder for which the item 

represents typical symptomatology. 

On the other hand, the MHSF-III is only a 

screening device as it asks only one question 

for each disorder for which it attempts to 

screen. If a client answers “no” because of a 

misunderstanding of the question or a 

momentary lapse in memory or test-taking 

attitude, the screen would produce a “falsenegative,” where the client might have the 

mental disorder but the screen falsely indicates that the person probably does not have 

the disorder. In a journal article the MHSFIII is referred to as a “rough screening 

device” (Carroll and McGinley 2001, p. 35), 

and the authors make suggestions about its 

use, comments about its limitations, and 

review favorable validity and reliability data. 

Counselors should

bear in mind that 

symptoms of mental 

disorder can be 

mimicked by

substances. 

Mini-International 

Neuropsychiatric Interview 

For a more complete screening instrument, the 

Mini-International 

Neuropsychiatric 

Interview (M.I.N.I.) 

is a simple 15- to 30­

minute device that 

covers 20 mental disorders, including 

substance use disorders. Considerable 

validation research 

has accumulated on 

the M.I.N.I. 

(Sheehan et al. 

1998). 

For each disorder 

the M.I.N.I. has an 

ordered series of about 6 to 12 questions, and 

it has a simple and immediate scoring procedure. For example, in terms of suicidality the 

M.I.N.I. contains questions about whether in 

the past month the client has 

1. Thought about being better off dead or 

wishing to be dead (1 point) 

2. Wanted to harm himself/herself (2 points) 

3. Thought about suicide (6 points) 

4. Attempted suicide (10 points) 

5. Developed a suicide plan (10 points) 

M.I.N.I. contains a sixth question asking if the 

client has ever attempted suicide (4 points). 

Scoring rates low current suicide risk as 1 to 5 

points, moderate as 6 to 9 points, and high as 

10 or more points. 

Assessment 79 
The M.I.N.I. family consists of

•The M.I.N.I. (a low­power, broad screening

device to see if the client requires further

assessment)

•A two­page M.I.N.I. screen for research purposes or when time is limited

•The M.I.N.I. Plus (an expanded version of

the M.I.N.I. designed specifically to determine whether symptoms were associated with

alcohol and other drug use and/or periods of

abstinence)

•The M.I.N.I. Tracking (a 17­page document

that provides symptom descriptors that can

be used to monitor a client’s progress in

treatment, monitor how a client’s symptoms

are affected by treatment interventions or

medications or other factors, and help with

documenting where, when, and why changes

occur)

Brief Symptom Inventory­18

Another proprietary instrument that can be

used to track clients from session to session or

over longer periods of time is the Brief

Symptom Inventory­18 (BSI­18). The BSI­18

questionnaire contains 18 items and asks

clients to rate each question on a five­point

scale. In addition to a Global Severity Index

score, there are separate scores for anxiety,

depression, and somatization subscales. The

BSI­18 was derived from the 53­item Brief

Symptom Inventory, which was derived from

the Symptom Checklist­90­Revised (SCL­90­R)

(Derogatis 1975), and the 15­item SDS

(McCorkle and Young 1978) also was a derivative of the BSI that has been superceded by the

relatively new BSI­18.

ASI

The ASI (McLellan et al. 1992) does not screen

for mental disorders and provides only a lowpower screen for generic mental health problems. Use of the ASI ranges widely, with some

substance abuse treatment programs using a

scaled­down approach to gather basic information about a client’s alcohol use, drug use, legal

status, employment, family/social, medical, and

psychiatric status, to an in­depth assessment

and treatment planning instrument to be

administered by a trained interviewer who

makes complex judgments about the client’s

presentation and ASI­taking attitudes.

Counselors can be trained to make clinical

judgments about how the client comes across,

how genuine and legitimate the client’s way of

responding seems, whether there are any safety

or self­harm concerns requiring further investigation, and where the client falls on a ninepoint scale for each dimension. With about 200

items, the ASI is a low­power instrument but

with a very broad range, covering the seven

areas mentioned above and requiring about 1

hour for the interview. Development of and

research into the ASI continues, including

training programs, computerization, and critical analyses. It is a public domain document

that has been used widely for 2 decades. It is

reproduced in TIP 38 as appendix D (CSAT

2000c, pp. 193–204), and information about

obtaining the manual for the ASI and up­todate information is in appendix G. Over the

past several years, NIDA’s Clinical Trials

Network (CTN) has been researching both the

use of and the training for the ASI.

Screening for past and present substance use disorder

This section is intended primarily for counselors working in mental health service settings.

It suggests ways to screen clients for substance

abuse problems.

Screening begins with inquiry about past and

present substance use and substance­related

problems and disorders. If the client answers

yes to having problems and/or a disorder, further assessment is warranted. It is important to

remember that if the client acknowledges a past

substance problem but states that it is now

resolved, assessment is still required. Careful

exploration of what current strategies the individual is using to prevent relapse is warranted.

Such information can help ensure that those

80 Assessment
strategies continue while the individual is focusing on mental health treatment. 

Screening for the presence of substance abuse 

symptoms and problems involves four components: 

• Substance abuse symptom checklists 

•Substance abuse severity checklists 

•Formal screening tools that work around 

denial 

•Screening of urine, saliva, or hair samples 

Symptom checklists: These include checklists 

of common categories of substances, history 

of associated problems with use, and a history 

of meeting criteria for substance dependence 

for that substance. It is not helpful to develop 

checklists that are overly detailed, because 

they begin to lose value as simple screening 

tools. It is helpful to remember to include 

abuse of over-the-counter medication (e.g., 

cold pills), abuse of prescribed medication, 

and gambling behavior in the checklist. It 

also is reasonable to screen for compulsive 

sexual behavior, Internet addiction, and compulsive spending. 

Severity checklists: It is useful to monitor the 

severity of substance use disorder (if present) 

and to determine the possible presence of 

dependence. This process can begin with simple questions about past or present diagnosis 

of substance dependence, and the client’s 

experience of associated difficulties. Some 

programs may use formal substance use disorder diagnostic tools; others use the ASI 

(McLellan et al. 1992) or similar instrument, 

even in the mental health setting. The New 

Hampshire Dartmouth Psychiatric Research 

Center has developed clinician-rated alcoholand drug-use scales for monitoring substance 

abuse severity in individuals with mental disorders: the Alcohol Use Scale (AUS) and 

Drug Use Scale (DUS) (Drake et al. 1996b) 

and others.

Screening tools: Most common substance 

abuse screening tools have been used with 

individuals with COD. These include the 

CAGE (Mayfield et al. 1974), the Michigan 

Alcoholism Screen Test (MAST) (Selzer 1971), 

the Drug Abuse Screening Test (DAST) 

(Skinner 1982), and the Alcohol Use 

Disorders Identification Test (AUDIT) (Babor 

et al. 1992). The Dartmouth Assessment of 

Lifestyle Inventory (DALI) is used routinely 

as a screening tool in some research settings 

working with individuals with serious mental 

disorders (Rosenberg et al. 1998). 

The SSI-SA was developed by the consensus 

panel of TIP 11, Simple Screening 

Instruments for Outreach for Alcohol and 

Other Drug Abuse 

and Infectious 

Diseases (CSAT 

1994c). The SSI-SA 

is reproduced in its 

entirety in appendix 

H. It is a 16-item 

scale, although only 

14 items are scored 

so that scores can 

range from 0 to 14. 

These 14 items were 

selected by the TIP 

11 consensus panelists from existing 

alcohol and drug 

abuse screening 

tools. A score of 4 

or greater has 


become the estab­


lished cut-off point 


for warranting a referral for a full assess­


ment. Since its publication in 1994 the SSI-SA 


has been widely used and its reliability and 


validity investigated. For example, Peters and 


colleagues (2004) reported on a national sur­


vey of correctional treatment for COD. 


Reviewing 20 COD treatment programs in 


correctional settings from 13 States, the SSI­


SA was identified as among the most common 


screening instruments used. For more infor­


mation, see appendix H. 


Screening begins

with inquiry

about past and

present substance use and 

substance-related problems and

disorders.

Toxicology screening: Given the high prevalence of substance use disorders in patients

with mental health problems, the routine use

Assessment 81 
The Four Quadrants 

III IV 

• Less severe mental disorder/more severe substance 

disorder 

• More severe mental disorder/more severe substance 

disorder 

I II 

• Less severe mental disorder/less severe substance 

disorder 

• More severe mental disorder/less severe substance 

disorder 

of urine or other screening is indicated for all 

new mental health clients. It especially is suggested in settings in which the likelihood of 

clients regularly presenting unreliable information is particularly great; for example, in 

adolescent and/or criminal justice settings. 

Use of urine screening is highly recommended 

whenever the clinical presentation does not 

seem to fit the client’s story, or where there 

appear to be unusual mental status symptoms 

or changes not explained adequately. Saliva 

testing may be less intrusive than hair or 

urine testing in patients who are shy or who 

are extremely paranoid. 

Trauma screening 

Research projects focusing on the needs of 

people with COD who are victims of trauma 

have led to the development of specific 

screening tools to identify trauma in treatment populations. To screen for posttraumatic stress disorder (PTSD), assuming the client 

has a trauma, the Modified PTSD Symptom 

Scale: Self-Report Version would be a good 

choice (this instrument can be found in TIP 

36, Substance Abuse Treatment for Persons 

With Child Abuse and Neglect Issues [CSAT 

2000d, p. 170]). This scale also is useful for 

monitoring and tracking PTSD symptoms 

over time. The PTSD Checklist (Blanchard et 

al. 1996) is a validated instrument that substance abuse treatment agencies also may find 

useful in trauma screening. 

It is important to emphasize that in screening 

for a history of trauma or in obtaining a preliminary diagnosis of PTSD, it can be damaging to ask the client to describe traumatic 

events in detail. To screen, it is important to 

limit questioning to very brief and general 

questions, such as “Have you ever experienced childhood physical abuse? Sexual 

abuse? A serious accident? Violence or the 

threat of it? Have there been experiences in 

your life that were so traumatic they left you 

unable to cope with day-to-day life?” See the 

discussion of screening and assessment for 

PTSD in appendix D for more complete information. 

Assessment Step 4: Determine 

Quadrant and Locus of 

Responsibility 

Determination of quadrant assignment is based 

on the severity of the mental and substance use 

disorders (see chapter 2 for a detailed discussion of the four-quadrant model). Most of the 

information needed for this determination will 

have been acquired during step 2, but there 

are a few added nuances. Quadrant determination may be specified formally by procedures in 

certain States. For example, New York has 

drafted (but not yet adopted) a set of objective 

criteria for determining at screening who 

should be considered as belonging in quadrant 

IV. Where no such formal procedures are present, the following sequence may be useful and 

is certainly within the capability of substance 

abuse treatment clinicians in any setting. 

82 Assessment 
Assessment Step 4—Application to Case Examples 

Cases 1 and 2. Both Maria M. and George T. are examples of clients with serious addiction who also have 

serious mental disorders, but do not appear to be seriously disabled. They would therefore meet criteria for 

quadrant III and should be placed in programs for people who have less serious mental disorders and more 

serious substance use disorders. Note that though the diagnosis of bipolar disorder is typically considered a 

serious mental illness, the quadrant system emphasizes the acute level of disability/severity of the mental 

and substance use disorders of the individual, rather than relying solely on diagnostic classification. 

Case 3. Jane B., the homeless woman with paranoid schizophrenia, generally would meet criteria for serious and persistent mental illness in almost every State, based on the severity of the diagnosis and disability, 

combined with the persistence of the disorder. Jane B. also has serious addiction. In the quadrant model, if 

she already has been identified as a mental health priority client (e.g., has a mental health case manager), 

she would be considered quadrant IV, and referral for mental health case management services would be 

important. 

Determination of serious 

mental illness (SMI) status 

Every State mental health system has developed a set of specific criteria for determining 

who can be considered seriously mentally ill 

(and therefore eligible to be considered a mental health priority client). These criteria are 

based on combinations of specific diagnoses, 

severity of disability, and duration of disability 

(usually 6 months to 1 year). Some require that 

the condition be independent of a substance 

use disorder. These criteria are different for 

every State. It would be helpful for substance 

abuse treatment providers to obtain copies of 

the criteria for their own States, as well as 

copies of the specific procedures by which eligibility is established by their States’ mental 

health systems. By determining that a client 

might be eligible for consideration as a mental 

health priority client, the substance abuse 

treatment counselor can assist the client in 

accessing a range of services and/or benefits 

that the client may not know is open to her or 

him. 

Determining SMI status begins with finding out 

if the client already is receiving mental health 

priority services (e.g., Do you have a mental 

health case manager? Are you a Department of 

Mental Health client?). 

• If the client already is a mental health 

client, then he or she will be assigned to 

quadrant II or IV. Contact needs to be 

made with the mental health case manager 

and a means of collaboration established to 

promote case management. 

• If the client is not already a mental health 

client, but appears to be eligible and the 

client and family are willing, referral for 

eligibility determination should be 

arranged. 

• Clients who present in addiction treatment 

settings who look as if they might be SMI, 

but have not been so determined, should be 

considered to belong to quadrant IV. 

For assistance in determination of the severity of symptoms and disability, the substance 

abuse treatment clinician can use the 

Dimension 3 (Emotional/Behavioral) subscales in the ASAM PPC-2R or LOCUS, especially the levels of severity of comorbidity and 

impairment/functionality. 

Determination of severity of 

substance use disorders 

Presence of active or unstable substance 

dependence or serious substance abuse (e.g., 

recurrent substance-induced psychosis without 

meeting other criteria for dependence) would 

identify the individual as being in quadrant III 

or IV. Less serious substance use disorder (mild 

to moderate substance abuse; substance depenAssessment 83 
dence in full or partial remission) identifies the 

individual as being in quadrant I or II. 

If the client is determined to have SMI with 

serious substance use disorder, he falls in 

quadrant IV; those with SMI and mild substance use disorder fall in quadrant II. A 

client with serious substance use disorder who 

has mental health symptoms that do not constitute SMI falls into quadrant III. A client 

with mild to moderate mental health symptoms and less serious substance use disorder 

falls into quadrant I. 

Clients in quadrant III who present in substance abuse treatment settings are often best 

managed by receiving care in the addiction 

treatment setting, with collaborative or consultative support from mental health 

providers. Individuals in quadrant IV usually 

require intensive intervention to stabilize and 

determination of eligibility for mental health 

services and appropriate locus of continuing 

care. If they do not meet criteria for SMI, 

once their more serious mental symptoms 

have stabilized and substance use is controlled initially, they begin to look like individuals in quadrant III, and can respond to 

similar services. 

Note, however, that this discussion of quadrant determination is not validated by clinical 

research. It is merely a practical approach to 

adapting an existing framework for clinical 

use, in advance of more formal processes 

being developed, tested, and disseminated. 

In many systems, the process of assessment 

stops largely after assessment step 4 with the 

determination of placement. Some information 

from subsequent steps (especially step 7) may 

be included in this initial process, but usually 

more in-depth or detailed consideration of 

treatment needs may not occur until after 

“placement” in an actual treatment setting. 

Assessment Step 5: Determine 

Level of Care 

The use of the ASAM PPC-2R provides a 

mechanism for an organized assessment of individuals presenting for substance use disorder 

treatment to determine appropriate placement 

in “level of care.” This process involves consideration of six dimensions of assessment: 

• Dimension 1: Acute Intoxication and/or 

Withdrawal Potential 

Assessment Step 5—Application to Case Examples 

Case 3. The severity of Jane B.’s condition and her psychosis, homelessness, and lack of stability may lead 

the clinician initially to consider psychiatric hospitalization or referral for residential substance abuse 

treatment. In fact, application of assessment criteria in ASAM PPC-2R might have led easily to that conclusion. In ASAM PPC-2R, more flexible matching is possible. The first consideration is whether the client 

meets criteria for involuntary psychiatric commitment (usually, suicidal or homicidal impulses, or inability 

to feed oneself or obtain shelter). In this instance, she is psychotic and homeless but has been able to find 

food and shelter; she is unwilling to accept voluntary mental health services. Further, residential substance 

abuse treatment is inappropriate, both because she is completely unmotivated to get help and because she is 

likely to be too psychotic to participate in treatment effectively. ASAM PPC-2R would therefore recommend Level I.5 intensive mental disorder case management as described above. 

If after extended participation in the engagement strategies described earlier, she began to take antipsychotic medication, after a period of time her psychosis might clear up, and she might begin to express interest in getting sober. In that case, if she had determined that she is unable to get sober on the street, residential substance abuse treatment would be indicated. Because of the longstanding severity of her mental illness, it is likely that she would continue to have some level of symptoms of her mental disorder and disability even when medicated. In this case, Jane B. probably would require a residential program able to supply 

an enhanced level of services. 

84 Assessment 
• Dimension 2: Biomedical Conditions and

Complications

• Dimension 3: Emotional, Behavioral, or

Cognitive Conditions and Complications

• Dimension 4: Readiness to Change

• Dimension 5: Relapse, Continued Use, or

Continued Problem Potential

• Dimension 6: Recovery/Living Environment

The ASAM PPC­2R (ASAM 2001) evaluates

level of care requirements for individuals with

COD. Dimension 3 encompasses “Emotional,

Behavioral or Cognitive Conditions and

Complications.” Five areas of risk must be considered related to this dimension (ASAM 2001,

pp. 283–284):

•Suicide potential and level of lethality

•Interference with addiction recovery efforts

(“The degree to which a patient is distracted

from addiction recovery efforts by emotional,

behavioral and/or cognitive problems and

conversely, the degree to which a patient is

able to focus on addiction recovery”)

•Social functioning

•Ability for self­care

•Course of illness (a prediction of the patient’s

likely response to treatment)

Consideration of these dimensions permits the

client to be placed in a particular level on a

continuum of services ranging from intensive

case management for individuals with serious

mental disorders who are not motivated to

change (Level I.5) to psychiatric inpatient care

(Level IV). In addition, there is the capacity to

distinguish, at each level of care, individuals

with lower severity of mental symptoms or

impairments that require standard or Dual

Diagnosis Capable programming at that level of

care from individuals with moderately severe

symptoms or impairments that require Dual

Diagnosis Enhanced programming at that level

of care. (See below for assessment of the level

of impairment.) The ASAM PPC have undergone limited validity testing in previous versions, are used to guide addiction treatment

matching in more than half the States, and are

influential in almost all of the rest.

Tools: The LOCI–2R (Hoffmann et al. 2001)

is a proprietary tool designed specifically to

perform a structured assessment for level of

care placement based on ASAM PPC­2R levels of care (ASAM 2001). The GAIN (Dennis

1998) is another broad set of tools and training developed within an addiction setting;

however, GAIN products are also proprietary.

In some systems, the LOCUS Adult Version

2000 (AACP 2000a) is being introduced as a

systemwide level of care assessment instrument for either mental health settings only, or

for both mental health and substance abuse

treatment settings. Like the ASAM, LOCUS

uses multiple dimensions of assessment:

•Risk of Harm

•Functionality

•Comorbidity (Medical, Addictive,

Psychiatric)

•Recovery Support and Stress

•Treatment Attitude and Engagement

•Treatment History

LOCUS is simpler to use than ASAM PPC­2R.

It has a point system for each dimension that

permits aggregate scoring to suggest level of service intensity. LOCUS also permits level of care

assessment for individuals with mental disorders or substance use disorders only, as well as

for those with COD. Some pilot studies of

LOCUS have supported its validity and reliability. However, compared to ASAM PC­2R,

LOCUS is much less sensitive to the needs of

individuals with substance use disorders and

has greater difficulty distinguishing the separate contributions of mental and substancerelated symptoms to the clinical picture.

Assessment 85
Assessment Step 6: Determine 

Diagnosis 

Determining the diagnosis can be a formidable 

clinical challenge in the assessment of COD. 

Clinicians in both mental health services and 

substance abuse treatment settings recognize 

that it can be impossible to establish a firm 

diagnosis when confronted with the mixed presentation of mental symptoms and ongoing substance abuse. Of course, substance abuse contributes to the emergence or severity of mental 

symptoms and therefore confounds the diagnostic picture. Therefore, this step often 

includes dealing with confusing diagnostic presentations. 

Addiction counselors who want to improve 

their competencies to address COD are urged 

to become conversant with the basic resource 

used to diagnose mental disorders, the 

Diagnostic and Statistical Manual of Mental 

Disorders, 4th Edition, Text Revision (DSMIV-TR) (American Psychiatric Association 

2000). 

The importance of client 

history 

• Principle #1: Diagnosis is established more 

by history than by current symptom presentation. This applies to both mental and 

substance use disorders. 

The first step in determining the diagnosis is to 

determine whether the client has an established 

diagnosis and/or is receiving ongoing treatment 

for an established disorder. This information 

can be obtained by the counselor as part of the 

routine intake process. If there is evidence of a 

disorder but the diagnosis and/or treatment 

recommendations are unclear, the counselor 

immediately should begin the process of obtaining this information from collaterals. If there is 

a valid history of a mental disorder diagnosis at 

admission to substance abuse treatment, that 

diagnosis should be considered presumptively 

valid for initial treatment planning, and any 

existing stabilizing treatment should be maintained. In addition to confirming an established 

diagnosis, the client’s history can provide 

insight into patterns that may emerge and add 

depth to knowledge of the client. 

For example, if a client comes into the clinician’s office under the influence of alcohol, it 

is reasonable to suspect alcohol dependence, 

but the only diagnosis that can be made based 

on that datum is “alcohol intoxication.” It is 

important to note that this warrants further 

investigation; on the one hand, false positives 

can occur, while on the other, detoxification 

may be needed. Conversely, if a client comes 

into the clinician’s office and has not had a 

drink in 10 years, attends Alcoholics 

Anonymous (AA) meetings three times per 

week, and had four previous detoxification 

admissions, the clinician can make a diagnosis 

of alcohol dependence (in remission at present). Moreover, the clinician can predict that 

20 years from now that client will still have 

the diagnosis of alcohol dependence since the 

history of alcohol dependence and treatment 

sustains a lifetime diagnosis of alcohol dependence. 

Similarly, if a client comes into the clinician’s 

office and says she hears voices (whether or 

Assessment Step 6—Application to Case Examples 

Case 2. George T. has cocaine dependence and bipolar disorder stabilized with lithium. He reports that 

when he uses cocaine he has mood swings, but that these go away when he stops using for a while, as long as 

he takes his medication. At the initial visit, George T. states he has not used for a week and has been taking 

his medication regularly. He displays no significant symptoms of mania or depression and appears reasonably calm. The counselor should not conclude that because George T. has no current symptoms the diagnosis of bipolar disorder is incorrect, or that all the mood swings are due to cocaine dependence. At initial 

contact, the presumption should be that the diagnosis of bipolar disorder is accurate, and lithium needs to 

be maintained. 

86 Assessment 
Assessment Step 6—Application to Case Example 

Case 1. Maria M., the 38-year-old Hispanic/Latina female with cocaine and opioid dependence, initially was 

receiving methadone maintenance treatment only. She also used antidepressants prescribed by her outside 

primary care physician. She presented to methadone maintenance program staff with complaints of depression. Maria M. reported that since treatment with methadone (1 year) she had not used illicit opioids. 

However, she stated that when she does not use cocaine, she often feels depressed “for no reason.” 

Nevertheless, she has many stressors involving her children, who also have drug problems. She reports that 

depression is associated with impulses to use cocaine, and consequently she has recurrent cocaine binges. 

These last a few days and are followed by persistent depression. 

What is the mental diagnosis? To answer this question it is important to obtain a mental disorder history 

that relates mental symptoms to particular time periods and patterns of substance use and abuse. 

The client’s history reveals that although she grew up with an abusive father with an alcohol problem, she 

herself was not abused physically or sexually. Although hampered by poor reading ability, she stayed in 

school with no substance abuse until she became pregnant at age 16 and dropped out of high school. Despite 

becoming a single mother at such a young age, she worked three jobs and functioned well, while her mother 

helped raise the baby. At age 23, she began a 9-year relationship with an abusive person with an alcohol and 

illicit drug problem, during which time she was exposed to a period of severe trauma and abuse. She is able 

to recall that during this relationship, she began to lose her self-esteem and experience persistent depression 

and anxiety. 

She began using cocaine at age 27, initially to relieve those symptoms. Later, she lost control and became 

addicted. Four years ago, she was first diagnosed as having major depression, and was prescribed antidepressant medication, which she found helpful. Two years ago, she began using opioids, became addicted, 

and then entered methadone treatment. She receives no specific treatment for cocaine dependence. She has 

noticed that her depression persists during periods of cocaine and opioid abstinence lasting more than 30 

days. On one occasion, during one of these periods, her medication ran out, and she noticed her depression 

became much worse. Even at her baseline, she remains troubled by lack of self-confidence and fearfulness, 

as well as depressed mood. 

Her depression persists during periods of more than 30 days of abstinence and responds to some degree to 

antidepressants. The fact that her depression persists even when she is abstinent and responds to antidepressants suggests strongly a co-occurring affective disorder. There are also indications of the persistent 

effects of trauma, possibly posttraumatic stress disorder. Trauma issues have never been addressed. Her 

opioid dependence has been stabilized with methadone. She has resisted recommendations to obtain more 

specific treatment for cocaine dependence. 

not the client is sober currently), no diagnosis 

should be made on that basis alone. There 

are many reasons people hear voices. They 

may be related to substance-related syndromes (e.g., substance-induced psychosis or 

hallucinosis, which is the experience of hearing voices that the client knows are not real, 

and that may say things that are distressing 

or attacking—particularly when there is a 

trauma history—but are not bizarre). With 

COD, most causes will be independent of substance use (e.g., schizophrenia, schizoaffective disorder, affective disorder with psychosis or dissociative hallucinosis related to 

PTSD). Psychosis usually involves loss of 

ability to tell that the voices are not real, and 

increased likelihood that they are bizarre in 

content. Methamphetamine psychosis is particularly confounding because it can mimic 

schizophrenia. Many individuals with psychotic disorders will still hear voices when on 

medication, but the medication makes the 

Assessment 87 
voices less bizarre and helps the client know 

they are not real. 

If the client states he has heard voices, 

though not as much as he used to, that he has 

been clean and sober for 4 years, that he 

remembers to take his medication most days 

though every now and then he forgets, and 

that he had multiple psychiatric hospitalizations for psychosis 10 years ago but none 

since, then the client clearly has a diagnosis 

of psychotic illness (probably schizophrenia 

or schizoaffective disorder). Given the client’s 

continuing symptoms while clean and sober 

and on medication, it is quite possible that 

the diagnosis will persist. 

Documenting prior diagnoses 

• Principle #2: It is important to document 

prior diagnoses and gather information 

related to current diagnoses, even though 

substance abuse treatment counselors may 

not be licensed to make a mental disorder 

diagnosis. 

Diagnoses established by history should not be 

changed at the point of initial assessment. If the 

clinician has a suspicion that a long-established 

diagnosis may be invalid, it is important that he 

or she takes time to gather additional information, consult with collaterals, get more careful 

and detailed history (see below), and develop a 

better relationship with the client before recommending diagnostic re-evaluation. It is 

important for the counselor to raise issues 

related to diagnosis with the clinical supervisor 

or at a team meeting. 

In many instances, of course, no well-established mental disorder diagnosis exists, or 

multiple diagnoses give a confusing picture. 

Even when there is an established diagnosis, 

it is helpful to gather information to confirm 

that diagnosis. During the initial assessment 

process, substance abuse treatment counselors can gather data that can assist in the 

diagnostic process, either by supporting the 

findings of the existing mental health assessment, or providing useful background information in the event a new mental health 

assessment is conducted. The key to doing 

this is not merely to gather lists of past and 

present symptoms, but to connect those symptoms to key time periods in the client’s life 

that are helpful in the diagnostic process— 

namely, before the onset of a substance use 

disorder and during periods of abstinence (or 

during periods of very limited use) or those 

that occur after the onset of the substance use 

disorder and persist for more than 30 days. 

The clinician also must seek to determine 

whether mental symptoms occur only when 

the client is using substances actively. 

Therefore, it is important to determine the 

nature and severity of the symptoms of the 

mental disorder when the substance disorder 

is stabilized. 

Linking mental symptoms to 

specific periods 

• Principle #3: For diagnostic purposes, it is 

almost always necessary to tie mental symptoms to specific periods of time in the 

client’s history, in particular those times 

when active substance use disorder was not 

present. 

Unfortunately, most substance abuse assessment tools are not structured to require connection of mental symptoms to such periods 

of use or abstinence. For this reason, mental 

disorder symptom information obtained from 

such tools can be confusing and often contributes to counselors feeling the whole process is not worth the effort. In fact, it is striking that when clinicians seek information 

about mental symptoms during periods of 

abstinence, such information is almost never 

part of traditional assessment forms. The 

mental history and substance use history have 

in the past been collected separately and 

independently. As a result, the opportunity to 

evaluate interaction, which is the most important diagnostic information beyond the history, has been routinely lost. Newer and more 

detailed assessment tools overcome these historical, unnecessary divisions. 

88 Assessment 
One instrument that may be helpful in this 

regard is the M.I.N.I. Plus (described above), 

which has a structure to connect any identified symptoms to periods of abstinence. 

Clinicians can use this information to distinguish substance-induced mental disorders 

from independent mental disorders. Drake 

and others in their work on mental disorder 

treatment teams in New Hampshire have 

adapted the Timeline Follow Back Method, 

developed by Sobell and Mueser 

(Mueser et al. 1995b; Sobell et al. 1979), that 

can be used with individuals who have serious 

mental disorders and substance use disorders. More detailed mental health research 

diagnostic tools (e.g., the SCID) encourage a 

similar process. 

Consequently, the substance abuse treatment 

counselor can proceed in two ways: 

1. Inquire whether any mental symptoms or 

treatments identified in the screening process were present during periods of 30 days 

of abstinence or longer, or were present 

before onset of substance use. (“Did this 

symptom or episode occur during a period 

when you were clean and sober for at least 

30 days?”) 

2. Define with the client specific time periods 

where substance use disorder was in remission, and then get detailed information 

about mental symptoms, diagnoses, impairments, and treatments during those periods 

of time. (“Can you recall a specific period 

when you were not using? Did these symptoms [or whatever the client has reported] 

occur during that period?”) This approach 

may yield more reliable information. 

During this latter process, the counselor can 

use one of the medium-power symptom screening tools as a guide. Alternatively, the counselor can use the handy outlines of the DSM-IV 

criteria for common disorders and inquire 

whether those criteria symptoms were met, 

whether they were diagnosed and treated, and 

if so, with what methods and how successfully. 

This information can suggest or support the 

accuracy of diagnoses. Documentation also can 

facilitate later diagnostic assessment by a mental-health–trained clinician. 

Assessment Step 7: Determine 

Disability and Functional 

Impairment 

Determination of both current and baseline 

functional impairment contributes to identification of the need for case management and/or 

higher levels of support. This step also relates 

to the determination of level of care requirements. Assessment of current cognitive capacity, social skills, and other functional abilities 

also is necessary to determine if there are 

deficits that may require modification in the 

treatment protocols of relapse prevention 

efforts or recovery programs. For example, the 

counselor might inquire about past participation in special education or related testing. 

Assessment Step 7—Application to Case Example 

Case 1. Assessment of Maria M.’s functional capacity at baseline indicated that she could read only at a 

second grade level. Consequently, educational materials presented in written form needed to be presented 

in alternative formats. These included audiotapes and videos to teach her about addiction, depression, 

trauma, and recovery from these conditions. In addition, Maria M.’s history of trauma (previously discussed) led her to experience anxiety in large group situations, particularly where men were present. This 

led her counselor to recommend attending 12-Step meetings that were smaller and/or women only. The 

counselor also suggested that she attend in the company of female peers. Further, the clinician referred her 

to trauma-specific counseling. 

Assessment 89 
Assessment Step 7—Application to Case Example 

Case 3. Once Jane B. had begun to stabilize on medication and expressed interest in residential addiction treatment, it became necessary to assess her ability to participate in standard dual diagnosis capable (DDC) treatment 

versus her need for more dual diagnosis enhanced (DDE) treatment. Jane B. was still living in a shelter, but was 

able to maintain her personal hygiene and dress appropriately now that she was on medication. She looked 

somewhat suspicious and guarded, but could answer questions appropriately and denied having hallucinations. 

To determine her ability to succeed in standard residential substance abuse treatment, her counselor asked her 

to attend an AA meeting. The clinician also asked her to complete an assignment to read some substance abuse 

literature and write down what she had learned. The client reported that she was nervous at the meeting but was 

able to stay the whole time. She said that she related well to what one of the speakers was saying. She also completed the written assignment quite well; it turned out she was very bright and had completed 1 year of college. 

Noting that she was complying with medication and her mental status was stable, the counselor felt comfortable 

referring her to the DDC program. 

Had this client been unable to attend AA without individual support, or if she experienced obvious difficulty 

with the assignment, it would have been clearer that a program with an enhanced capacity to treat persons with 

COD would be indicated. If such a program were not available, she would have needed to continue to build skills 

slowly to address her substance use with the assistance of her outpatient case management program. 

Assessing functional 

capability 

Current level of impairment is determined by 

assessing functional capabilities and deficits in 

each of the areas listed below. Similarly, baseline level of impairment is determined by identifying periods of extended abstinence and 

mental health stability (greater than 30 days) 

according to the methods described in the previous assessment step. The clinician determines: 

•Is the client capable of living independently 

(in terms of independent living skills, not in 

terms of maintaining abstinence)? If not, 

what types of support are needed? 

•Is the client capable of supporting himself 

financially? If so, through what means? If 

not, is the client disabled, or dependent on 

others for financial support? 

•Can the client engage in reasonable social 

relationships? Are there good social supports? If not, what interferes with this ability, 

and what supports would the client need? 

•What is the client’s level of intelligence? Is 

there a developmental or learning disability? 

Are there cognitive or memory impairments 

that impede learning? Is the client limited in 

ability to read, write, or understand? Are 

there difficulties with focusing, concentrating, and completing tasks? 

The ASI (McLellan et al. 1992) and the GAIN 

(Dennis 1998) provide some information 

about level of functioning for individuals with 

substance use disorders. They are valuable 

when supplemented by interview information 

in the above areas. (Note that the ASI also 

exists in an expanded version specifically for 

women [ASI-F, CSAT 1997c].) The counselor 

also should inquire about any current or past 

difficulties the client has had in learning or 

using relapse prevention skills, participating 

in self-help recovery programs, or obtaining 

medication or following medication regimens. 

In the same vein, the clinician may inquire 

about use of transportation, budgeting, selfcare, and other related skills, and their 

effect on life functioning and treatment 

participation. 

For individuals with COD, the impairment 

may be related to intellectual/cognitive ability 

or the mental disability. These disorders may 

exist in addition to the substance use disor90 Assessment 
der. The clinician should try to establish both 

level of intellectual/cognitive functioning in 

childhood and whether any impairment persists, and if so, at what level, during the periods when substance use is in full or partial 

remission, just as in the above discussion of 

diagnosis. 

Determining the need for 

“Capable” or “Enhanced” 

level services 

A specific tool to assess the need for 

“Capable” or “Enhanced” level services for 

persons with COD currently is not available. 

The consensus panel recommends a process of 

“practical assessment” that seeks to match 

the client’s assessment (mental health, substance abuse, level of impairment) to the type 

of services needed. The individual may even 

be given trial tasks or assignments to determine in concert with the counselor if her performance meets the requirements of the program being considered. 

Assessment Step 8: Identify 

Strengths and Supports 

All assessment must include some specific 

attention to the individual’s current strengths, 

skills, and supports, both in relation to general 

life functioning, and in relation to his or her 

ability to manage either mental or substance 

use disorders. This often provides a more positive approach to treatment engagement than 

does focusing exclusively on deficits that need 

to be corrected. This is no less true for individuals with serious mental disorders than it is for 

people with substance use disorders only. 

Questions might focus on 

• Talents and interests 

• Areas of educational interest and literacy; 

vocational skill, interest, and ability, such as 

vocational skills, social skills, or capacity for 

creative self-expression 

• Areas connected with high levels of motivation to change, for either disorder or both 

• Existing supportive relationships, treatment, 

peer, or family, particularly ongoing mental 

disorder treatment relationships 

• Previous mental health services and addiction treatment successes, and exploration of 

what worked 

• Identification of current successes: What has 

the client done right recently, for either disorder? 

• Building treatment plans and interventions 

based on utilizing and reinforcing strengths, 

and extending or supporting what has 

worked previously 

Assessment Step 8—Application to Case Examples 

Case 2. George T. had significant strengths in three areas: He had a strong desire to maintain his family, 

significant pride in his job, and attachment to a mutual self-help group for individuals with bipolar disorder—Manic-Depressive and Depressive Association (MDDA). Therefore his treatment plan involved attending a recovery group managed by the Employee Assistance Program (EAP) at his company (which included 

regularly monitored urine screens), family counseling sessions, and utilization of his weekly MDDA group 

for peer support. Despite not feeling engaged fully, George T. continued to attend 12-Step meetings two 

times per week, as there was no Dual Recovery Anonymous or Double Trouble meeting available in his area. 

Case 3. Jane B. expressed significant interest in work, once her paranoia subsided. She was attempting to 

address her substance use on an outpatient basis, as an appropriate residential treatment program was not 

available. Her case management team found that she had some interest and experience in caring for animals, and, using individualized placement and support, helped her obtain a part-time job at a local pet shop 

two afternoons per week. She felt very proud of being able to do this, and reported that this helped her to 

maintain her motivation to stay away from substances and to keep taking medication. 

Assessment 91 
For individuals with mental disabilities and 

COD, the Individualized Placement and 

Support model of psychiatric rehabilitation has 

been demonstrated to promote better vocational outcomes and (consequently) better substance abuse outcomes compared both to other 

models of vocational rehabilitation for this population and to outcomes when rehabilitative 

interventions are not offered (Becker et al. 

2001). In this model, clients with disabilities 

who want to work may be placed in sheltered 

work activities based on strengths and preferences, even when actively using substances and 

inconsistently complying with medication regimens. In nonsheltered work activities, it is critical to remember that many employers have 

alcohol- and drug-free workplace policies. 

Participating in ongoing jobs is valuable to selfesteem in itself and can generate the motivation 

to address mental disorders and substance 

issues as they appear to interfere specifically 

with work success. Taking advantage of educational and volunteer opportunities also may 

enhance self-esteem and are often first steps in 

securing employment. 

Social Security Disability secondary to a mental disorder, such as schizophrenia, usually is 

referred to as Supplemental Security Income 

(if the person never worked regularly), or 

Social Security Disability Insurance (if the 

person worked regularly and contributed 

social security payments while working). To 

qualify as having a mental disability, a person 

must have not only a confirmed major mental 

disorder diagnosis, but also a pattern related 

to the impact of that mental disorder diagnosis on his social and functional behavior that 

prevents employment. Social security disability benefits for an addiction disorder alone 

were abandoned by the Federal government 

in 1997. For persons with COD, disability 

must be caused by the mental disorder alone 

and not the combination of both mental and 

addiction disorders. Social security disability 

evaluation forms ask carefully about these 

issues and also ask whether the person is 

actively participating in treatments for their 

COD and substance abuse problems. 

Assessment Step 9: Identify 

Cultural and Linguistic Needs 

and Supports 

As noted above, detailed cultural assessment of 

individuals with substance use disorders is 

beyond the scope of this chapter. Cultural 

assessment of individuals with COD is not substantially different from cultural assessment for 

individuals with substance abuse or mental disorders only, but there are some specific issues 

that are worth addressing. These include 

• Not fitting into the treatment culture (do not 

fit into either substance abuse or mental 

health treatment culture) and conflict in 

treatment 

• Cultural and linguistic service barriers 

• Problems with literacy 

Not fitting into the 

treatment culture 

To a certain degree, individuals with COD and 

SMI tend not to fit into existing treatment cultures. Most of these clients are aware of a variety of different attitudes and suggestions 

toward their disorders that can affect relationships with others. Traditional culture carriers 

(parents, grandparents) may have different 

Assessment Step 9—Application to Case Example 

Case 1. Maria M. initially had difficulty identifying herself as being a victim of trauma both because she 

had normalized her perception of her early family experience with her abusive father and because she had 

received cultural reinforcement in the past that condoned the behavior of her abusive boyfriend as “normal machismo.” Referral to a group that included other Hispanic women who also had suffered abuse was 

very helpful to her. With the help of the group, she began to recognize the reality of the impact that trauma 

had had in her life. 

92 Assessment 
views of their problems and the most appropriate treatment compared to peers. Individual 

clients may have positive or negative allegiance 

to a variety of peer or treatment cultures (e.g., 

mental health consumer movement, having 

mild or moderate severity mental disorders 

versus severe and persistent mental illness 

[SPMI], 12-Step or dual recovery self-help, 

etc.) based on past experience or on fears and 

concerns related to the mental disorder. 

Specific considerations to explore with the 

client include 

•How are your substance abuse and mental 

health problems defined by your parents? 

Peers? Other clients? 

•What do they think you should be doing to 

remedy these problems? 

•How do you decide which suggestions to 

follow? 

•In what kinds of treatment settings do you 

feel most comfortable? 

•What do you think I (the counselor) should 

be doing to help you improve your situation? 

Assessment Step 9—Application to Case Example 

Case 2. George T. originally was referred to Cocaine Anonymous (CA) by his counselor because the counselor knew of several local meetings with a large membership of African-American men. When George T. 

went, however, he reported back to the counselor that he did not feel comfortable there. First, he felt that 

as a family man with a responsible job he had pulled himself out of the “street culture” that was prevalent 

at the meeting. Second, unlike many people with COD who feel more ashamed of mental disorders than 

addiction, he felt more ashamed at the CA meeting than at his support group for persons with mental disorders. Therefore, for George, it was more “culturally appropriate” to refer him to 12-Step meetings attended 

by other middle class individuals (regardless of race) and to continue to encourage him to attend his MDDA 

support group for his mental disorder. 

Cultural and linguistic 

service barriers 

Access to COD treatment is compounded by 

cultural or linguistic barriers. The assessment 

process must address specifically whether these 

barriers prevent access to care (e.g., the client 

reads or speaks only Spanish, or does not read 

any language) and if so, determine some possibilities for providing more individualized intervention or for integrating intervention into naturalistic culturally and linguistically appropriate human service settings. 

Assessment Step 10: Identify 

Problem Domains 

Individuals with COD may have difficulties in 

multiple life domains (e.g., medical, legal, 

vocational, family, social). As noted earlier, 

research by McLellan and others has determined the value of providing assistance in 

each problem area in promoting better outcomes (McLellan et al. 1997). The ASI is a 

tool that is used widely to identify and quantify addiction-related problems in multiple 

Assessment Step 10—Application to Case Example 

Case 2. Evaluation of George T. revealed several interrelated problem domains. First, it was established 

that work represented a major problem area, and that he risked losing his job if he did not comply with 

treatment. Further inquiry into the details of this expectation led the counselor to discover that the client 

had been evaluated by the EAP and had a very specific requirement to maintain cocaine abstinence with 

mandatory urine screens, meet treatment program attendance requirements, and adhere to a lithium treatment regimen, with mandatory reports of lithium levels. 

Assessment 93 
domains, thereby determining which domains 

require specific attention. The value of the 

ASI is that it permits identification of problem domains. It is used most effectively as a 

component of a comprehensive assessment. 

A comprehensive evaluation for individuals 

with COD requires clarifying how each disorder interacts with the problems in each 

domain, as well as identifying contingencies 

that might promote treatment adherence for 

mental health and/or substance abuse treatment. Information about others who might 

assist in the implementation of such contingencies (e.g., probation officers, family, 

friends) needs to be gathered, including 

appropriate releases of information. 

Assessment Step 11: 

Determine Stage of Change 

A key evidence-based best practice for treatment matching of individuals with COD in both 

substance abuse treatment and mental health 

services settings is the following: 

•For each disorder or problem, interventions 

have to be matched not only to specific diagnosis, but also to stage of change; the interventions also should be consistent with the 

stage of treatment for each disorder. 

In substance abuse treatment settings, stage of 

change assessment usually involves determination of Prochaska and DiClemente Stages of 

Change: precontemplation, contemplation, 

preparation (or determination), action, maintenance, and relapse (Prochaska and DiClemente 

1992). This can involve using questionnaires 

such as the URICA (McConnaughy et al. 1983) 

or the Stages of Change Readiness and 

Treatment Eagerness Scale (SOCRATES) 

(Miller and Tonigan 1996). It also can be determined clinically by interviewing the client and 

evaluating the client’s responses in terms of 

stages of change. For example, a simple 

approach to identification of stage of change 

can be the following. 

For each problem, select the statement that 

most closely fits the client’s view of that 

problem: 

• No problem and/or no interest in change 

(Precontemplation) 

• Might be a problem; might consider change 

(Contemplation) 

• Definitely a problem; getting ready to change 

(Preparation) 

• Actively working on changing, even if slowly 

(Action) 

• Has achieved stability, and is trying to maintain (Maintenance) 

Stage of change assessment ideally will be 

applied separately to each mental disorder and 

to each substance use disorder. For example, a 

client may be willing to take medication for a 

depressive disorder, but unwilling to discuss 

trauma issues (as in case 1, Maria M.); or motivated to stop cocaine, but unwilling to consider 

alcohol as a problem (as in case 2, George T.). 

Assessment Step 11—Application to Case Example 

A 50-year-old Liberian woman with a diagnosis of paranoid schizophrenia, Lila B. illustrates the existence of 

differential stages of change for mental and substance abuse problems. The client permitted the case manager nurse to come to her home to give her intramuscular antipsychotic injections for her “nerves,” but would 

not agree to engage in any other treatment activity or acknowledge having a serious mental disorder. She 

also had significant alcohol dependence, with an alcohol level of 0.25 to 0.3 most of the time, with high tolerance. She denied adamantly that she had used alcohol in the last 18 months, stating that her liver was 

impaired and therefore unable to get rid of the alcohol. She was able to agree that she had a “mysterious 

alcohol level problem” that might warrant medical hospitalization for testing and perhaps treatment, as well 

as evaluation of her recent onset rectal bleeding. 

94 Assessment 
Although literature supporting the importance 

of stage-specific treatment has been available in 

both mental health and addiction literature for 

over a decade, very few programs routinely 

evaluate stage of change for the purpose of 

treatment matching. 

In mental health settings working with individuals with SMI, the Substance Abuse Treatment 

Scale (SATS) (McHugo et al. 1995) is recommended strongly. This is a case-manager 

rated scale with eight items identified by the 

degree of the client’s engagement in treatment. 

The stages are:

•Pre-Engagement 

•Engagement 

•Early Persuasion 

•Late Persuasion 

•Early Active Treatment 

•Late Active Treatment 

•Relapse Prevention 

•Remission 

For more in-depth discussion of the stages of 

change and motivational enhancement, the 

reader is referred to TIP 35, Enhancing 

Motivation for Change in Substance Abuse 

Treatment (CSAT 1999b). 

Assessment Step 12: 

Plan Treatment 

A major goal of the screening and assessment 

process is to ensure the client is matched with 

appropriate treatment. Acknowledging the 

overriding importance of this goal, this discussion of the process of clinical assessment for 

individuals with COD begins with a fundamental statement of principle: 

•Since clients with COD are not all the same, 

program placements and treatment interventions should be matched individually to the 

needs of each client. 

The ultimate purpose of the assessment process 

is to develop an appropriately individualized 

integrated treatment plan. In this model, following the work of McLellan on comprehensive 

services for populations with substance use disorders, Minkoff on COD, and others, the consensus panel recommends the following 

approach: 

• Treatment planning for individuals with COD 

and associated problems should be designed 

according to the principle of mental disorder 

dual (or multiple) primary treatment, where 

each disorder or problem has a specific intervention that is matched to problem or diagnosis, as well as to stage of change and external contingencies. Figure 4-2 (p. 96) shows a 

sample treatment plan consisting of the problem, intervention, and goal. 

• Integrated treatment planning involves helping the client to make the best possible treatment choices for each disorder and adhere to 

that treatment consistently. At the same time, 

the counselor needs to help the client adjust 

the recommended treatment strategies for 

each disorder as needed in order to take into 

account issues related to the other disorder. 

These principles are best illustrated by using a 

case example to develop a sample treatment 

plan. For this purpose, case 2 (George T.) is 

used and incorporates the data gathered during 

the assessment process discussion above (see 

Figure 4-1). Note that the problem description 

presents a variety of information bearing on 

the problem, including stage of change and 

client strengths. Also note that no specific person is recommended to carry out the intervention proposed in the second column, since a 

range of professionals might carry out each 

intervention appropriately. 

Considerations in Treatment 

Matching 

Previous chapters introduced a variety of concepts for categorizing individuals with COD 

and the clinicians, programs, and systems 

responsible for serving those individuals. The 

consensus panel has identified critical factors 

that have been determined, either by research 

evidence or by consensus clinical practice, to 

be relevant to the process of matching individuAssessment 95 
Figure 4-2 

Sample Treatment Plan for George T. (Case 2) 

PROBLEM INTERVENTION GOAL 

1. Cocaine Dependence Outpatient treatment Abstinence 

•

•

•

•

•

Work problem primary rea­ • 

• 

• 

• 

• 

EAP monitoring •

• 

Clean urines 

son for referral Family meetings Daily recovery plans 

Family and work support Work support group 

Resists 12-Step Teach skills to manage symptoms 

Mental symptoms trigger use without using 

Action phase 12-Step meetings 

2. Rule Out Alcohol Abuse 

• 

• 

• 

No clear problem 

May trigger cocaine use 

Precontemplation 

• Outpatient motivational 

enhancement; thorough evaluation of role of alcohol in patient’s 

life, including family education 

• 

• 

Move into contemplation phase 

of readiness to change 

Willing to consider the risk of 

use and/or possible abuse 

3. Bipolar Disorder • 

• 

•

•

• 

Medication management • 

• 

Maintain stable mood 

• 

• 

• 

• 

Long history Help to take medication while in Able to manage fluctuating mood 

On lithium recovery programs symptoms that do occur without 

Some mood symptoms 

Maintenance phase 

MDDA meetings 

Advocate/collaborate with prescribing health professional 

Identify mood symptoms that are 

triggers 

using cocaine or other substances 

to regulate his bipolar disorder 

al clients to available treatment. These considerations are shown in Figure 4-3. 

Assessment Process Summary 

The assessment process described above is a 

systematic approach for substance abuse treatment clinicians (and mental health clinicians) to 

gather the information needed to develop 

appropriately matched treatment plans for 

individuals with COD. The most important 

question about this process, from the clinician’s 

standpoint, is the following: 

But—can this really be done? 

To answer the question, this process is 

approached from the perspective of a real system. Many public sector substance abuse treatment systems already define assessment procedures that require use of a level of care assessment tool (often the ASAM, but sometimes a 

State-derived version of the ASAM) and a comprehensive addiction severity and outcome 

measure (such as the ASI [McLellan et al. 

1992]). How can the assessment process 

described here be built on these existing assessment procedures in a reasonably efficient 

manner? 

The first steps involve engaging the client, 

gathering information from family and other 

providers, and beginning to screen for the 

presence of mental symptoms and disorders. 

The ASAM PPC-2R (and other level of care 

tools, such as LOCUS) will provide a reason96 Assessment 
Figure 4-3 

Considerations in Treatment Matching 

Variable Key Data 

Acute Safety Needs • 

• 

• 

• 

• 

• 

Immediate risk of harm to self or others 

Determines need for immediate acute stabilization to 

establish safety prior to routine assessment 

Immediate risk of physical harm or abuse from others (ASAM 2001) 

Inability to provide for basic self-care 

Medically dangerous intoxication or withdrawal 

Potentially lethal medical condition 

Acute severe mental symptoms (e.g., mania, psychosis) leading to inability to function or communicate 

effectively 

Quadrant Assignment • 

• 

• 

•

SPMI versus non-SPMI 

Guides the choice of the most appropriate setting for 

treatment 

Severely acute and/or disabling mental symptoms 

versus mild to moderate severity symptoms 

High severity substance use disorder (e.g., active 

substance dependence) versus lower severity substance use disorder (e.g., substance abuse) 

 Substance dependence in full versus partial remission (ASAM 2001; National Association of State 

Mental Health Program Directors/National 

Association of State Alcohol and Drug Abuse 

Directors 1999) 

Level of Care 

Determines the client’s program assignment 

• Dimensions of assessment for each disorder using 

criteria from ASAM PPC-2R and/or the LOCUS 

(see chapter 2) 

Diagnosis 

Determines the recommended treatment intervention 

•

• 

• 

 Specific diagnosis of each mental and substance use 

disorder, including distinction between substance 

abuse and substance dependence and substanceinduced symptoms 

Information about past and present successful and 

unsuccessful treatment efforts for each diagnosis 

Identification of trauma-related disorders and culture-bound syndromes, in addition to other mental 

disorders and substance-related problems 

Assessment 97 
Figure 4-3 (continued) 

Considerations in Treatment Matching 

Disability 

Determines case management needs and whether a 

standard intervention is sufficient—one that is at the 

“capable” or intermediate level—or whether a more 

advanced “enhanced” level intervention is essential 

•

• 

• 

 Cognitive deficits, functional deficits, and skill 

deficits that interfere with ability to function independently and/or follow treatment recommendations and which may require varying types and 

amounts of case management and/or support 

Specific functional deficits that may interfere with 

ability to participate in substance abuse treatment 

in a particular program setting and may therefore 

require a DDE setting rather than DDC 

Specific deficits in learning or using basic recovery 

skills that require modified or simplified learning 

strategies 

Strengths and Skills 

Determines areas of prior success around which to 

organize future treatment interventions 

Determines areas of skills building needed for disease 

management of either disorder 

• 

• 

Areas of particular capacity or motivation in relation to general life functioning (e.g., capacity to 

socialize, work, or obtain housing) 

Ability to manage treatment participation for any 

disorder (e.g., familiarity and comfort with 12-Step 

programs, commitment to medication adherence) 

Availability and Continuity of Recovery Support •

•

Presence or absence of continuing treatment relationships, particularly mental disorder treatment Determines whether continuing relationships need to relationships, beyond the single episode of care be established and availability of existing relationships to provide contingencies to promote learning Presence or absence of an existing and ongoing supportive family, peer support, or therapeutic community; quality and safety of recovery environment 

(ASAM 2001) 

Cultural Context 

Determines most culturally appropriate treatment 

interventions and settings 

• 

• 

• 

• 

• 

• 

Areas of cultural identification and support in relation to each of the following 

Ethnic or linguistic culture identification (e.g., 

attachment to traditional American-Indian cultural 

healing practices) 

Cultures that have evolved around treatment of 

mental and/or substance use disorders (e.g., identification with 12-Step recovery culture; commitment 

to mental health empowerment movement) 

Gender 

Sexual orientation 

Rural versus urban 

98 Assessment 
Figure 4-3 (continued) 

Considerations in Treatment Matching 

Problem Domains 

Determines problems to be solved specifically, and 

opportities for contingencies to promote treatment 

participation 

Is there impairment, need, or (conversely) strength in 

any of the following areas 

• 

• 

• 

• 

• 

•

Financial 

Legal 

Employment 

Housing 

Social/family 

Medical, parenting/child protective, abuse/victimization/victimizer 

Note: Each area of need may be associated with the 

presence of contingencies and/or supports that may 

affect treatment motivation and participation 

(McLellan et al. 1993, 1997) 

Phase of Recovery/Stage of Change (for each problem) 

Determines appropriate phase-specific or stage-specific treatment intervention and outcomes 

• 

• 

• 

• 

• 

• 

Requirement for acute stabilization of symptoms, 

engagement, and/or motivational enhancement 

Active treatment to achieve prolonged stabilization 

Relapse prevention/maintenance 

Rehabilitation, recovery, and growth 

Within the motivational enhancement sequence, 

precontemplation, contemplation, preparation, 

action, maintenance, or relapse (Prochaska and 

DiClemente 1992) 

Engagement, persuasion, active treatment, or 

relapse prevention (McHugo et al. 1995; Osher and 

Kofoed 1989) 

able way of screening for acute safety issues 

and presence of persistent mental disorders 

and disability. The ASI also provides a lowpower screen for mental health difficulties 

(McLellan et al. 1992). These tools alone can 

provide a beginning picture of whether there 

is a need for acute mental health services 

intervention, ongoing case management, 

and/or in-depth mental assessment. The consensus panel recommends use of a low- or 

medium-power symptom screening tools in 

addition to low-power tools (e.g., M.I.N.I. or 

Mental Health Screening Form [Carroll and 

McGinley 2001]), but in many settings, ASAM 

plus ASI will suffice. 

Next, the information gathered from ASAM 

and ASI can give a sufficient picture of mental impairment and substance use disorder 

severity to promote quadrant identification, 

and the ASAM itself clearly is used to identify 

level of care. The ASI further screens for 

problem domains, including a beginning picture of mental health disability. 

Finally, ASAM PPC-2R includes attention to 

stage of change for both mental health and 

Assessment 99 
substance-related issues in dimension 4. 

Other level of care tools cover similar ground. 

Through the assessment process, the counselor seeks to accomplish the following aims: 

•To obtain a more detailed chronological history of past mental symptoms, diagnosis, treatment, and impairment, particularly before 

the onset of substance abuse, and during 

periods of extended abstinence. 

•To obtain a more detailed description of 

current strengths, supports, limitations, 

skill deficits, and cultural barriers related 

to following the recommended treatment 

regime for any disorder or problem. 

•To determine the stage of change for each 

problem, and identify external contingencies that might help to promote treatment 

adherence. 

Most of these activities are already a natural 

component of substance abuse-only assessment; 

the key addition is to attend to treatment 

requirements and stage of change for mental 

disorders, and the possible interference of 

mental health symptoms and disabilities 

(including personality disorder symptoms) in 

addiction treatment participation. 

100 Assessment 
5 Strategies for Working 

With Clients With CoOccurring Disorders 

In This 

Chapter... 

Guidelines for a



Successful



Therapeutic



Relationship With
 


a Client Who Has



COD 
 

Techniques for
 


Working With
 


Clients With COD
 


Overview 

Maintaining a therapeutic alliance with clients who have co-occurring 

disorders (COD) is important—and difficult. The first section of this 

chapter reviews guidelines for addressing these challenges. It stresses the 

importance of the counselor’s ability to manage feelings and biases that 

could arise when working with clients with COD (sometimes called countertransference). Together, clinicians and clients should monitor the 

client’s disorders by examining the status of each disorder and alerting 

each other to signs of relapse. The consensus panel recommends that 

counselors use primarily a supportive, empathic, and culturally appropriate approach when working with clients with COD. With some clients 

who have COD, it is important to distinguish behaviors and beliefs that 

are cultural in origin from those indicative of a mental disorder. Finally, 

counselors should increase structure and support to help their clients 

with COD make steady progress throughout recovery. 

The second part of this chapter describes techniques effective in counseling clients with COD. One is the use of motivational enhancement consistent with the client’s specific stage of recovery. This strategy is helpful 

even for clients whose mental disorder is severe. Other strategies include 

contingency management, relapse prevention, and cognitive–behavioral 

techniques. For clients with functional deficits in areas such as understanding instructions, repetition and skill-building strategies can aid 

progress. Finally, 12-Step and other dual recovery mutual self-help 

groups have value as a means of supporting individuals with COD in the 

abstinent life. Clinicians often play an important role in facilitating the 

participation of these clients in such groups. This chapter will provide a 

basic overview of how counselors can apply each of these strategies to 

their clients who have COD. The material in this chapter is consistent 

with national or State consensus practice guidelines for COD treatment, 

and consonant with many of their recommendations. 

101 
The purpose of this chapter is to describe for 

the addiction counselor and other practitioners 

how these guidelines and techniques, many of 

which are useful in the treatment of substance 

abuse or as general treatment principles, can 

be modified specifically and applied to people 

with COD. These guidelines and techniques are 

particularly relevant in working with clients in 

quadrants II and III. Additionally, this chapter 

contains Advice to the Counselor boxes to highlight the most immediate practical guidance 

(for a full listing of these boxes see the table of 

contents). 

Guidelines for a 

Successful Therapeutic 

Relationship With a 

Client Who Has COD 

The following section reviews seven guidelines 

that have been found to be particularly helpful in forming a therapeutic relationship with 

clients who have COD (see text box below). 

Develop and Use a 

Therapeutic Alliance To 

Engage the Client in 

Treatment 

General. Research suggests that a therapeutic 

alliance is “one of the most robust predictors 

of treatment outcome” in psychotherapy 

(Najavits et al. 2000, p. 2172). Some studies 

in the substance abuse treatment field also 

have found associations between the strength 

of the therapeutic alliance and counseling 

effectiveness. One research team found that 

both clinician and client ratings of the 

alliance were strong predictors of alcoholic 

outpatients’ treatment participation in treatment, drinking behavior during treatment, 

and drinking behavior at a 12-month followup, even after controlling for a variety of 

other sources of variance (Connors et al. 

1997). Similarly, Luborsky and colleagues 

(1985) found that the development of a “helping alliance” was correlated with positive outcomes. 

A number of researchers have verified that 

clients are more responsive when the therapist acts consistently as a nurturing and nonjudgmental ally (Frank and Gunderson 1990; 

Luborsky et al. 1997; Siris and Docherty 

1990; Ziedonis and D’Avanzo 1998). For 

example, in a study of clients with opioid 

dependence and psychopathology, Petry and 

Bickel (1999) found that among clients with 

moderate to severe psychiatric problems, 

fewer than 25 percent of those with weak 

therapeutic alliances completed treatment, 

while more than 75 percent of those with 

strong therapeutic alliances completed treatment. In this study, they did not find the 

strength of the therapeutic alliance to be 

Guidelines for Developing Successful Therapeutic 

Relationships With Clients With COD 

1. Develop and use a therapeutic alliance to engage the client in treatment 

2. Maintain a recovery perspective 

3. Manage countertransference 

4. Monitor psychiatric symptoms 

5. Use supportive and empathic counseling 

6. Employ culturally appropriate methods 

7. Increase structure and support 

102 Strategies for Working With Clients With Co-Occurring Disorders 
related to treatment completion 

among clients with few psychiatric symptoms. 

Challenges for the 

clinician 

General. The clinician’s ease in 

working toward a therapeutic 

alliance also is affected by his or 

her comfort level in working with 

the client. Substance abuse counselors may find some clients with 

significant mental illnesses or 

severe substance use disorders to 

be threatening or unsettling. It is 

therefore important to recognize 

certain patterns that invite these 

feelings and not to let them interfere with the client’s treatment. 

This discomfort may be due to a 

lack of experience, training, or mentoring. 

Likewise, some mental health clinicians may 

feel uncomfortable or intimidated by clients 

with substance use disorders. Clinicians who 

experience difficulty forming a therapeutic 

alliance with clients with COD are advised to 

consider whether this is related to the client’s 

difficulties; to a limitation in the clinician’s 

own experience and skills; to demographic 

differences between the clinician and the 

client in areas such as age, gender, education, 

race, or ethnicity; or to issues involving countertransference (see the discussion of countertransference below). A consultation with a 

supervisor or peer to discuss this issue is 

important. Often these reactions can be overcome with further experience, training, 

supervision, and mentoring. 

Individuals with COD often experience 

demoralization and despair because of the 

complexity of having two problems and the 

difficulty of achieving treatment success. 

Inspiring hope often is a necessary precursor 

for the client to give up short-term relief in 

exchange for long-term work with some 

uncertainty as to timeframe and benefit. 

Advice to the Counselor: 

Forming a Therapeutic Alliance 

The consensus panel recommends the following 

approaches for forming a therapeutic alliance with 

clients with COD: 

• Demonstrate an understanding and acceptance of the 

client. 

• Help the client clarify the nature of his difficulty. 

• Indicate that you and the client will be working 

together. 

• Communicate to the client that you will be helping her 

to help herself. 

• Express empathy and a willingness to listen to the client’s 

formulation of the problem. 

• Assist the client to solve some external problems directly 

and immediately. 

Challenges in working with clients with serious mental and substance use disorders. 

Achieving a therapeutic alliance with clients 

with serious mental illness and substance use 

disorders can be challenging. According to 

Ziedonis and D’Avanzo (1998), many people 

who abuse substances also may have some 

antisocial traits. Such individuals are “less 

amenable to psychological and pharmacological interventions and avoid contact with the 

mental health treatment staff.” Therefore, it 

is reasonable to conclude that “the dually 

diagnosed are less likely to develop a positive 

therapeutic alliance than non–substanceabusing patients with schizophrenia...” (p. 

443). 

Individuals with both schizophrenia and a 

substance use disorder may be particularly 

challenging to treat. These individuals “present and maintain a less involved and more 

distant stance in relation to the therapist than 

do non–substance-abusing individuals with 

schizophrenia” (Ziedonis and D’Avanzo 1998, 

Strategies for Working With Clients With Co-Occurring Disorders 103 
p. 443). The presence or level of these deficits 

may vary widely for people living with 

schizophrenia, and also may vary significantly for that individual within the course of his 

illness and the course of his lifetime. While 

“this configuration of interpersonal style suggests that developing a therapeutic alliance 

can be difficult,” Ziedonis and D’Avanzo 

insist, “working with the dually diagnosed 

requires a primary focus on the therapeutic 

alliance” (Ziedonis and D’Avanzo 1998, p. 

444). 

For all clients with co-occurring disorders, the 

therapeutic relationship must build on the 

capacity that does exist. These clients often 

need the therapeutic alliance to foster not only 

their engagement in treatment but as the cornerstone of the entire recovery process. Once 

established, the therapeutic alliance is rewarding for both client and clinician and facilitates 

their participation in a full range of therapeutic 

activities; documentation of these types of 

interactions provides an advantage in risk 

management. 

Maintain a Recovery 

Perspective 

Varied meanings of 

“recovery” 

The word “recovery” has different meanings in 

different contexts. Substance abuse treatment 

clinicians may think of a person who has 

changed his or her substance abuse behavior as 

being “in recovery” for the rest of his or her 

life (although not necessarily in formal treatment forever). Mental health clinicians, on the 

other hand, may think of recovery as a process 

in which the client moves toward specific 

behavioral goals through a series of stages. 

Recovery is assessed by whether or not these 

goals are achieved. For persons involved with 

12-Step programs, recovery implies not only 

abstinence from drugs or alcohol but also a 

commitment to “work the steps,” which 

includes changing the way they interact with 

others and taking responsibility for their 

actions. Consumers with mental disorders may 

see recovery as the process of reclaiming a 

meaningful life beyond mental disorder, with 

symptom control and positive life activity. 

While “recovery” has many meanings, generally, it is recognized that recovery does not refer 

solely to a change in substance use, but also to 

a change in an unhealthy way of living. 

Markers such as improved health, better ability to care for oneself and others, a higher 

degree of independence, and enhanced selfworth are all indicators of progress in the 

recovery process. 

Implications of the recovery 

perspective 

The recovery perspective as developed in the 

substance abuse field has two main features: 

(1) It acknowledges that recovery is a long-term 

process of internal change, and (2) it recognizes 

that these internal changes proceed through 

various stages (see De Leon 1996 and 

Prochaska et al. 1992 for a detailed description). 

The recovery perspective generates at least two 

main principles for practice: 

• Develop a treatment plan that provides 

for continuity of care over time. In 

preparing this plan, the clinician should 

recognize that treatment may occur in different settings over time (e.g., residential, 

outpatient) and that much of the recovery 

process is client-driven and occurs typically 

outside of or following professional treatment (e.g., through participation in mutual 

self-help groups) and the counselor should 

reinforce long-term participation in these 

constantly available settings. 

• Devise treatment interventions that are 

specific to the tasks and challenges 

faced at each stage of the COD recovery process. The use of treatment interventions that are specific to the tasks and 

challenges faced at each stage of the COD 

recovery process enables the clinician 

(whether within the substance abuse or 

mental health treatment system) to use sen104 Strategies for Working With Clients With Co-Occurring Disorders 
Advice to the Counselor: 

Maintaining a Recovery Perspective 

The consensus panel recommends the following approaches for maintaining a recovery perspective with 

clients who have COD: 

• Assess the client’s stage of change (see section on 

Motivational Enhancement below). 

• Ensure that the treatment stage (or treatment expectations) is (are) consistent with the client’s stage of change. 

• Use client empowerment as part of the motivation for 

change. 

• Foster continuous support. 

• Provide continuity of treatment. 

• Recognize that recovery is a long-term process and that 

even small gains by the client should be supported and 

applauded. 

sible stepwise approaches in developing and 

using treatment protocols. In addition, 

markers that are unique to individuals— 

such as those related to their cultural, 

social, or spiritual context—should be considered. It is therefore important to engage 

the client in defining markers of progress 

that are meaningful to him and to each 

stage of recovery. 

Stages of change and stages 

of treatment 

Working within the recovery perspective 

requires a thorough understanding of the 

interrelationship between stages of change 

(see De Leon 1996 and Prochaska et al. 1992) 

and stages of treatment (see section on motivational enhancement below for a description 

of the stages of change; see also TIP 35, 

Enhancing Motivation for Change in 

Substance Abuse Treatment [Center for 

Substance Abuse Treatment (CSAT) 1999b]). 

De Leon has developed a measure of motivation for change and readiness for treatment— 

The Circumstances, Motivation and 

Readiness Scales—and provided scores for 

samples of persons with COD (De Leon et al. 

2000a). De Leon has demonstrated the relationship between these scales and retention in 

treatment for general substance 

abuse treatment populations and 

programs (De Leon 1996). It is 

important that the expectation for 

the client’s progress through treatment stages (e.g., outreach, stabilization, early-middle-late primary 

treatment, continuing care, and 

long-term care/cycles into and out 

of treatment) be consistent with 

the client’s stage of change. 

Client empowerment 

and responsibility 

The recovery perspective also 

emphasizes the empowerment and 

responsibility of the client and the 

client’s network of family and significant others. As observed by the 

American Association of 

Community Psychiatrists (AACP), the strong 

client empowerment movement within the mental health field is a cornerstone for recovery: 

Pessimistic attitudes about people with COD 

represent major barriers to successful system 

change and to effective treatment interventions ... recovery is defined as a process by 

which a person with persistent, possibly disabling disorders, recovers self-esteem, selfworth, pride, dignity, and meaning, through 

increasing his or her ability to maintain stabilization of the disorders and maximizing 

functioning within the constraints of the disorders. As a general principle, every person, 

regardless of the severity and disability associated with each disorder, is entitled to experience the promise and hope of dual recovery, and is considered to have the potential to 

achieve dual recovery (AACP 2000b). 

Continuous support 

Another implication of the recovery perspective 

is the need for continuing support for recovery. 

This means the provider encourages clients to 

build a support network that offers respect, 

acceptance, and appreciation. For example, an 

important element of long-term participation in 

Strategies for Working With Clients With Co-Occurring Disorders 105 
Alcoholics Anonymous (AA) is the offering of a 

place of belonging or a “home.” AA accomplishes this supportive environment without 

producing overdependence because the client is 

expected to contribute, as well as receive, 

support. 

Continuity of treatment 

An emphasis on continuity of treatment also 

flows from a recovery perspective. Continuity 

of treatment implies that the services provided 

by the program are constant, and a client 

might remain a consumer of substance abuse or 

mental health services indefinitely. Treatment 

continuity for individuals with COD begins 

with proper and thorough identification, 

assessment, and diagnosis. It includes easy and 

early access to the appropriate service 

providers “...through multiple episodes of 

acute and subacute treatment ... independent 

of any particular setting or locus of care” 

(AACP 2000b). 

Advice to the Counselor: 

Managing Countertransference 

The consensus panel recommends the following 

approach for managing countertransference with clients 

who have COD: 

• The clinician should be aware of strong personal reactions and biases toward the client.		

• The clinician should obtain further supervision where 

countertransference is suspected and may be interfering 

with counseling. 

• Clinicians should have formal and periodic clinical 

supervision to discuss countertransference issues with 

their supervisors and the opportunity to discuss these 

issues at clinical team meetings. 

Manage Countertransference 

Though somewhat dated and infrequently used 

in the COD literature, the concept of “countertransference” is useful for understanding how 

the clinician’s past experience can influence 

current attitudes toward a particular client. 

“Transference” describes the process whereby 

clients project attitudes, feelings, reactions, 

and images from the past onto the clinician. 

For example, the client may regard the clinician as an “authoritative father,” “know-it-all 

older brother,” or “interfering mother.” 

Once considered a technical error, countertransference now is understood to be part of 

the treatment experience for the clinician. 

Particularly when working with multiple and 

complicated problems, clinicians are vulnerable to the same feelings of pessimism, despair, 

anger, and the desire to abandon treatment as 

the client. Inexperienced clinicians often are 

confused and ashamed when faced with feelings 

of anger and resentment that can result from 

situations where there is a relative absence of 

gratification from working with clients with 

these disorders (Cramer 2002). Less experienced practitioners may have more difficulty 

identifying countertransference, accessing feelings evoked by interactions with a client, naming them, and working to keep these feelings 

from interfering with the counseling relationship. 

Both substance use disorders and mental disorders are illnesses that are stigmatized by the 

general public. These same attitudes can be 

present among clinicians. Mental health clinicians who usually do not treat persons with 

substance abuse issues may not 

have worked out their own 

response to the disorder, which 

can influence their interactions

with the client. Similarly, substance abuse treatment clinicians 

may not be aware of their own

reactions to persons with specific 

mental disorders and may have 

difficulty preventing these reactions from influencing treatment.

The clinician’s negative attitudes 

or beliefs may be communicated,

directly or subtly, to the client. 

For example: “I was depressed

too, but I never took medications

for it—I just worked the steps

106 Strategies for Working With Clients With Co-Occurring Disorders 
and got over it. So why should this guy need 

medication?” 

Such feelings often are related to burnout and 

are exacerbated by the long time required to 

see progress in many clients with COD. For 

example, one study found that therapists’ attitudes toward their substance abuse clients 

tended to become more negative over time, 

though the increasing negativity was found to 

be less extreme for substance abuse counselors 

without graduate degrees who used the 12 steps 

to inform their counseling approach than for 

psychotherapists with graduate training who 

participated in the study (Najavits et al. 1995). 

(For a full discussion of countertransference in 

substance abuse treatment see Powell and 

Brodsky 1993.) 

Cultural issues also may arouse strong and 

often unspoken feelings and, therefore, generate transference and countertransference. 

Although counselors working with clients in 

their area of expertise may be familiar with 

countertransference issues, working with an 

unfamiliar population will introduce different 

kinds and combinations of feelings. 

The clinician is advised to understand and be 

familiar with some of the issues related to countertransference and strategies to manage it. 

Such countertransference issues are particularly important when working with 

persons with COD because many 

people with substance abuse and 

mental disorders may evoke 

strong feelings in the clinician that 

could become barriers to treatment if the provider allows them 

to interfere. The clinician may 

feel angry, used, overwhelmed, 

confused, anxious, uncertain how 

to proceed with a case, or just 

worn out. 

Monitor Psychiatric 

Symptoms 

In working with clients who have 

COD, especially those requiring 

medications or who also are 

receiving therapy from a mental health services 

provider, it is especially important for the substance abuse counselor to participate in the 

development of the treatment plan and to monitor psychiatric symptoms. At a minimum, the 

clinician should be knowledgeable about the 

overall treatment plan to permit reinforcement 

of the mental health part of the plan as well as 

the part specific to recovery from addiction. 

It is equally important that the client participate in the development of the treatment plan. 

For example, for a client who has both bipolar 

disorder and alcoholism, and who is receiving 

treatment at both a substance abuse treatment 

agency and a local mental health center, the 

treatment plan might include individual substance abuse treatment counseling, medication 

management, and group therapy. In another 

example, the substance abuse treatment clinician may assist in medication monitoring of a 

person taking lithium. The clinician can ask 

such questions as, “How are your meds doing? 

Are you remembering to take them? Are you 

having any problems with them? Do you need 

to check in with the prescribing doctor?” It also 

is prudent to ask the client to bring in all medications and ask the client how he is taking 

them, when, how much, and if medication is 

helping and how. Clinicians should help educate clients about the effects of medication, 

teach clients to monitor themselves (if possible), 

Advice to the Counselor: 

Monitoring Psychiatric Symptoms

The consensus panel recommends the following 

approaches for monitoring psychiatric symptoms with 

clients with COD: 

• Obtain a mental status examination to evaluate the

client’s overall mental health and danger profile. Ask 

questions about the client’s symptoms and use of medication and look for signs of the mental disorder 

regularly. 

• Keep track of changes in symptoms. 

• Ask the client directly and regularly about the extent of 

his or her depression and any associated suicidal

thoughts.

Strategies for Working With Clients With Co-Occurring Disorders 107 
and consult with clients’ physicians whenever 

appropriate. 

Status of symptoms 

Substance abuse counselors need to have a 

method by which to monitor changes in severity 

and number of symptoms over time. For example, most clients present for substance abuse 

treatment with some degree of anxiety or 

depressive symptoms. As discussed in chapters 

2 and 4, these symptoms are referred to as substance induced if caused by substances and 

resolved within 30 days of abstinence. 

Substance-induced symptoms tend to follow the 

“teeter totter” principle of “what goes up, must 

come down,” and vice versa—so that after a 

run of amphetamine or cocaine the individual 

will appear fatigued and depressed, while after 

using depressants such as alcohol or opioids, 

the individual more likely will appear agitated 

and anxious. These “teeter totter” symptoms 

are substance withdrawal effects and usually 

are seen for days or weeks. They may be followed by a substance-related depression (which 

can be seen as a neurotransmitter depletion 

state), which should begin to improve within a 

few weeks. If depressive or other symptoms 

persist, then a co-occurring (additional) mental 

disorder is likely, and the differential diagnostic process ensues. These symptoms may be 

appropriate target symptoms for establishing a 

diagnosis or determining treatment choices 

(medication, therapy, etc.). Clients using 

methamphetamines may present with psychotic 

symptoms that require medications. 

A number of different tools are available to 

substance abuse treatment providers to help 

monitor psychiatric symptoms. Some tools are 

simply questions and require no formal instrument. For example, to gauge the status of 

depression quickly, ask the client: “On a scale 

of 0 to 10, how depressed are you? (0 is your 

best day, 10 is your worst).” This simple scale, 

used from session to session, can provide much 

useful information. Adherence to prescribed 

medication also should be monitored by asking 

the client regularly for information about its 

use and effect. 

To identify changes, it is important to track 

symptoms that the client mentions at the onset 

of treatment from week to week. The clinician 

should keep track of any suggestions made to 

the client to alleviate symptoms to determine 

whether the client followed through, and if so, 

with what result. For example: “Last week you 

mentioned low appetite, sleeplessness, and a 

sense of hopelessness. Are these symptoms better or worse now?” 

Potential for harm to 

self or others 

Blumenthal (1988) has written an important 

paper on suicide and the risk for suicide in 

clients with COD. The following is derived 

largely from her writing. 

Suicidality is a major concern for many clients 

with COD. Persons with mental disorders are 

at 10 times greater risk for suicide than the 

general population, and the risk for suicidal 

behavior and suicide is increased with almost 

every major mental disorder. Of adults who 

commit suicide, 90 percent have a mental disorder, most frequently a major affective illness 

or posttraumatic stress disorder (PTSD). 

Alcohol and substance abuse often are associated with suicides and also represent major risk 

factors. Clients with COD—especially those 

with affective disorders—have two of the highest risk factors for suicide. 

For clients who mention or appear to be experiencing depression or sadness, it is always 

important to explore the extent to which suicidal thinking is present. Similarly, a client who 

reports that he or she is thinking of doing harm 

to someone else should be monitored closely. 

The clinician always should ask explicitly about 

suicide or the intention to do harm to someone 

else when the client assessment indicates that 

either is an issue. 

In addition to asking the client about suicidal 

thoughts and plans as a routine part of every 

session with a suicidal or depressed person, 

Blumenthal stresses that the clinician should 

immediately follow up appointments missed 

108 Strategies for Working With Clients With Co-Occurring Disorders 
by an acutely suicidal person. Management of 

the suicidal client requires securing an appropriate mental health professional for the 

client and having the client monitored closely 

by that mental health professional. The counselor also should have 24-hour coverage available, such as a hotline for the client to call for 

help during off hours. However, there are 

effective ways of managing individuals who 

have suicidal thoughts but no immediate plan, 

and are willing and able to contact the counselor in the event these thoughts become too 

strong, prior to action. See the more extensive discussion of suicidality in chapter 8 and 

in appendix D of this TIP. Screening for suicide risk is discussed in chapter 4. 

Use Supportive and Empathic 

Counseling 

Definition and importance 

A supportive and empathic counseling style is 

one of the keys to establishing an effective therapeutic alliance. According to Ormont, empathy is the ability to “experience another person’s feeling or attitude while still holding on to 

our own attitude and outlook”; it is the foundation adults use for relating to and interacting 

with other adults (Ormont 1999, p. 145). The 

clinician’s empathy enables clients to begin to 

recognize and own their feelings, an essential 

step toward managing them and learning to 

empathize with the feelings of others. 

However, this type of counseling must be used 

consistently over time to keep the alliance 

intact. This caveat often is critical for clients 

with COD, who usually have lower motivation 

to address either their mental or substance 

abuse problems, have greater difficulty 

understanding and relating to other people, 

and need even more understanding and support to make a major lifestyle change such as 

adopting abstinence. Support and empathy 

on the clinician’s part can help maintain the 

therapeutic alliance, increase client motivation, assist with medication adherence, model 

behavior that can help the client build more 

productive relationships, and support the 

client as he or she makes a major life transition. 

Using an Empathic Style 

Empathy is a key skill for the counselor, without which little could be accomplished. The practice of empathy 

“requires sharp attention to each new client statement, and a continual generation of hypotheses as to the 

underlying meaning” (Miller and Rollnick 1991, p. 26). An empathic style 

•Communicates respect for and acceptance of clients and their feelings 

•Encourages a nonjudgmental, collaborative relationship 

•Allows the clinician to be a supportive and knowledgeable consultant 

•Compliments and reinforces the client whenever possible 

•Listens rather than tells 

•Gently persuades, with the understanding that the decision to change is the client’s 

•Provides support throughout the recovery process 

(See also TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment [CSAT 1999b], p. 41.) 

Confrontation and empathy 

The overall utility of confrontational techniques is well accepted in the substance abuse 

literature. It is used widely in substance abuse 

treatment programs, including those surveyed 

in the Drug Abuse Treatment Outcomes Study 

in which the effectiveness of such programs was 

demonstrated. Confrontation is a form of interpersonal exchange in which individuals present 

Strategies for Working With Clients With Co-Occurring Disorders 109 
to each other their observations of, and reactions to, behaviors and attitudes that are matters of concern and should change (De Leon 

2000b). 

In substance abuse treatment counseling, 

some tension always is felt between being 

empathic and supportive, and having to handle minimization, evasion, dishonesty, and 

denial. However, a counselor can be empathic 

and firm at the same time. This is especially 

true when working with clients with COD. 

The heart of confrontation is not the aggressive breaking down of the client and his or 

her defenses, but feedback on behavior and 

the compelling appeal to the client for personal honesty, truthfulness in interacting with 

others, and responsible behavior. A straightforward and factual presentation of conflicting material or of problematic behavior in an 

inquisitive and caring manner can be both 

“confrontative” and caring. The ability to do 

this well and with balance often is critical in 

maintaining the therapeutic alliance with a 

client who has COD. Chapter 6 includes a 

more complete discussion of confrontation 

including a definition, description of its application, and suggested modifications for using 

this technique with clients who have COD. 

Employ Culturally Appropriate 

Methods 

Understanding the client’s 

cultural background 

It is well known that population shifts are 

resulting in increasing numbers of minority 

racial and ethnic groups in the United States. 

Each geographic area has its own cultural mix, 

and providers are advised to learn as much as 

possible about the cultures represented in their 

treatment populations. Of particular importance are the backgrounds of those served, 

conventions of interpersonal communication, 

understanding of healing, views of mental disorder, and perception of substance abuse. 

To work effectively with persons of various 

cultural groups, the provider should learn as 

much as possible about characteristics of the 

cultural group such as communication style, 

interpersonal interactions, and expectations 

of family. For example, some cultures may 

tend to somaticize symptoms of mental disorders, and clients from such groups may 

expect the clinician to offer relief for physical 

complaints. The same client may be offended 

by too many probing, personal questions 

early in treatment and never return. 

Similarly, understanding the client’s role in 

the family and its cultural significance always 

is important (e.g., expectations of the oldest 

son, a daughter’s responsibilities to her parents, grandmother as matriarch). 

At the same time, the clinician should not 

make assumptions about any client based on 

his or her perception of the client’s culture. 

The level of acculturation and the specific 

experiences of an individual may result in 

that person identifying with the dominant culture, or even other cultures. For example, a 

person from India adopted by American parents at an early age may know little about the 

cultural practices in his birth country. For 

such clients, it is still important to recognize 

the birth country and discover what this association means to the client; however, it may 

exert little influence on his beliefs and practices. For more detailed information about 

cultural issues in substance abuse treatment, 

see the forthcoming TIP Improving Cultural 

Competence in Substance Abuse Treatment 

(CSAT in development a). 

Clients’ perceptions of substance abuse, mental disorders, and healing 

Clients may have culturally driven concepts of 

what it means to abuse substances or to have a 

mental disorder, what causes these disorders, 

and how they may be “cured.” Clinicians are 

encouraged to explore these concepts with people who are familiar with the cultures represented in their client population. Counselors 

should be alert to differences in how their role 

and the healing process are perceived by persons who are of cultures other than their own. 

110 Strategies for Working With Clients With Co-Occurring Disorders 
Advice to the Counselor: 

Using Culturally Appropriate Methods 

The consensus panel recommends the following 

approach for using culturally appropriate treatment 

methods with clients with COD: 

• Take cultural context, background, and experiences into 

account in the evaluation, diagnosis, and treatment of 

clients from various groups, cultures, or countries. 	

• Recognize the importance of culture and language, 	

acknowledging the cultural strengths of a people. 

• Adapt services to meet the unique needs and value systems of persons in all groups. 	

• Expand and update [the provider’s/system’s] cultural 

knowledge. 

• Work on stigma reduction with a culturally sensitive 

approach. 

Source: Center for Mental Health Services 2001. 

Wherever appropriate, familiar healing practices meaningful to these clients should be 

integrated into treatment. An example would 

be the use of acupuncture to calm a Chinese 

client or help control cravings, or the use of 

traditional herbal tobacco with some 

American Indians to establish rapport and 

aid emotional balance. 

Cultural perceptions and 

diagnosis 

It is important to be aware of cultural and ethnic bias in diagnosis. For example, in the past 

some African Americans were stereotyped as 

having paranoid personality disorders, while 

women have been diagnosed frequently as 

being histrionic. American Indians with spiritual visions have been misdiagnosed as delusional 

or as having borderline or schizotypal personality disorders. Some clinicians would be likely 

to over diagnose obsessive-compulsive disorder 

among Germans or histrionic disorder in 

Hispanic/Latino populations. The diagnostic 

criteria should be tempered by sensitivity to 

cultural differences in behavior and emotional 

expression and by an awareness of

the clinician’s own biases and 


stereotyping. 


Cultural differences 

and treatment: 

Empirical

evidence on 

effectiveness 

Studies related to cultural differences and treatment issues among 

clients with COD are scarce. 

However, one study that compared 

nonwhite and white clients with

COD who were treated in mental

health settings suggests issues that

deserve providers’ attention. 

Researchers found that AfricanAmerican, Asian-American, and 

Hispanic/Latino clients tended to 

self-report a lower level of functioning and to be “viewed by clinical staff as suffering from more severe and persistent symptomatology and as having lower psychosocial functioning.” Researchers noted “this was due in 

part to the chronicity of their mental disorders 

and persistent substance abuse, but also was 

magnified by cross-cultural misperceptions; for 

example, system bias, countertransference, or 

inadequate support systems” (Jerrell and

Wilson 1997, p. 138). 

The study also found that nonwhite clients

tended to have fewer community resources

available to them than white clients, and that 

clinicians had more difficulty connecting them

with needed services. For example, staff

members experienced “extraordinary difficulties in identifying willing and suitable sponsors for the young ethnic clients” in 12-Step

programs (Jerrell and Wilson 1997, p. 138). 

To address such issues, researchers stressed 

the importance of developing cultural competence in staff, giving extra attention to the

needs of such clients, and engaging in “more

active advocacy for needed, culturally relevant services” (Jerrell and Wilson 1997, 

p. 139). 

Strategies for Working With Clients With Co-Occurring Disorders 111 
Increase Structure and 

Support 

To assist clients with COD, counselors should 

provide an optimal amount of structure for the 

individual. Free time is both a trigger for substance use cravings and a negative influence for 

many individuals with mental disorders; therefore it is a particular issue for clients with 

COD. Strategies for managing free time include 

structuring one’s day to have meaningful activities and to avoid activities that will be risky. 

Clinicians often help clients to plan their time 

(especially weekends). Creating new pleasurable activities can both help depression and 

help derive “highs” from sources other than 

substance use. Other important activities to 

include are working on vocational and relationship issues. 

In addition to structure, it is also important 

that the daily activities contain opportunities 

for receiving support and encouragement. 

Counselors should work with clients to create 

a healthy support system of friends, family, 

and activities. Increasing support, time organization, and structured activities are strategies in cognitive–behavioral therapies (see 

section below) for both mental disorders and 

substance abuse treatment. 

Techniques for 

Working With Clients 

With COD 

The following section reviews techniques, mainly from the substance abuse field, that have 

been found to be particularly helpful in the 

treatment of clients with substance abuse and

that are being adapted for work with clients 

with COD (see text box below). 

Provide Motivational 

Enhancement Consistent With 

the Client’s Specific Stage of 

Change 

Definition and description 

Motivational Interviewing (MI) is a “client-centered, directive method for enhancing intrinsic 

motivation to change by exploring and resolving ambivalence” (Miller and Rollnick 2002, p. 

25). MI has proven effective in helping clients 

clarify goals and make commitment to change 

(CSAT 1999b; Miller 1996; Miller and Rollnick 

2002; Rollnick and Miller 1995). This approach 

shows so much promise that it is one of the first 

two psychosocial treatments being sponsored in 

multisite trials in the National Institute on 

Drug Abuse (NIDA) Clinical Trials Network 

program. 

As Miller and Rollnick have pointed out, MI 

is “a way of being with a client, not just a set 

of techniques for doing counseling” (Miller 

and Rollnick 1991, p. 62). This approach 

involves accepting a client’s level of motivation, whatever it is, as the only possible starting point for change. For example, if a client 

says she has no interest in changing her 

drinking amounts or frequency, but only is 

interested in complying with the interview to 

be eligible for something else (such as the 

right to return to work or a housing voucher),

the clinician would avoid argumentation or 

Key Techniques for Working With Clients Who Have COD 

1. Provide motivational enhancement consistent with the client’s specific stage of change. 

2. Design contingency management techniques to address specific target behaviors. 

3. Use cognitive–behavioral therapeutic techniques. 

4. Use relapse prevention techniques. 

5. Use repetition and skills-building to address deficits in functioning. 

6. Facilitate client participation in mutual self-help groups. 

112 Strategies for Working With Clients With Co-Occurring Disorders 
confrontation in favor of establishing a positive rapport with the client—even remarking 

on the positive aspect of the client wishing to 

return to work or taking care of herself by 

obtaining housing. The clinician would seek 

to probe the areas in which the client does 

have motivation to change. The clinician is 

interested in eventually having an impact on 

the client’s drinking or drug use, but the 

strategy is to get to that point by working with 

available openings. 

A variety of adaptations of MI have emerged. 

Examples include brief negotiation, motivational consulting, and motivational enhancement therapy (MET). MET combines the clinical style associated with MI with systematic 

feedback of assessment results in the hope of 

producing rapid, internally motivated 

change. For more information, see the 

Project MATCH Motivational Enhancement 

Therapy Manual (National Institute on 

Alcohol Abuse and Alcoholism 1994). 

Rollnick and other practitioners of MI find 

that the many variants differ widely in their 

reliance on the key principles and elements of 

MI (Miller and Rollnick 2002). 

Guiding principles of motivational interviewing 

The four principles outlined below guide the 

practice of MI (see text box p. 114). In this section, each principle is summarized. For each 

principle, some of the related strategies that 

practitioners use when applying this principle 

to client interactions are highlighted. 

1. Expressing empathy 

Miller and Rollnick state that “an empathic 

counseling style is one fundamental and defining characteristic of motivational interviewing” 

(Miller and Rollnick 2002, p. 37). The counselor refrains from judging the client; instead, 

through respectful, reflective listening, the 

counselor projects an attitude of acceptance. 

This acceptance of the person’s perspectives 

does not imply agreement. It “does not prohibit 

the counselor from differing with the client’s 

views and expressing that divergence” (Miller 

and Rollnick 2002, p. 37). It simply accepts the 

individual’s ambivalence to change as normal 

and expected behavior in the human family. 

Practitioners find that projecting acceptance 

rather than censure helps free the client to 

change (Miller and Rollnick 2002). 

2. Developing discrepancies 

While recognizing the client’s ambivalence to 

change as normal, the counselor is not neutral 

or ambivalent about the need for change. The 

counselor advances the cause of change not by 

insisting on it, but by helping the client perceive the discrepancy between the current situation and the client’s personal goals (such as a 

supportive family, successful employment, and 

good health). The task of the counselor is to 

call attention to this discrepancy between “the 

present state of affairs and how one wants it to 

be,” making it even more significant and larger 

in the client’s eyes. The client is therefore more 

likely to change, because he sees that the current behavior is impeding progress to his 

goals—not the counselor’s (Miller and Rollnick 

2002, p. 39). 

3. Rolling with resistance 

Practitioners believe that “the least desirable 

situation, from the standpoint of evoking 

change, is for the counselor to advocate for 

change while the client argues against it” 

(Miller and Rollnick 2002, p. 39). The desired 

situation is for clients themselves to make the 

argument for change. Therefore, when resistance is encountered, the counselor does not 

oppose it outright. Instead, the counselor offers 

new information and alternative perspectives, 

giving the client respectful permission to “take 

what you want and leave the rest” (Miller and 

Rollnick 2002, p. 40). 

The counselor’s response to resistance can 

defuse or inflame it. Miller and Rollnick 

describe a number of techniques the skillful 

clinician can use when resistance is encountered. For example, the counselor may use varStrategies for Working With Clients With Co-Occurring Disorders 113 
Guiding Principles of Motivational Interviewing 

Source: Miller and Rollnick 2002, pp. 36–41. 

1. Express empathy • 

• 

• 

Acceptance facilitates change. 

Skillful reflective listening is fundamental. 

Ambivalence is normal. 

2. Develop discrepancy • 

• 

The client rather than the counselor should present the arguments for change. 

Change is motivated by a perceived discrepancy between present behavior and 

important personal goals or values. 

3. Roll with resistance • 

• 

• 

• 

• 

Avoid arguing for change. 

Resistance is not opposed directly. 

New perspectives are invited but not imposed. 

The client is a primary resource in finding answers and solutions. 

Resistance is a signal to respond differently. 

4. Support self-efficacy • 

• 

• 

A person’s belief in the possibility of change is an important motivator. 

The client, not the counselor, is responsible for choosing and carrying out 

change. 

The counselor’s own belief in the person’s ability to change becomes a self-fulfilling prophecy. 

ious forms of reflection, shift the focus of discussion, reframe the client’s observation, or 

emphasize the client’s personal choice or control. While description of these and other specific techniques for “rolling with resistance” is 

beyond the scope of this TIP, the reader is 

referred to chapter 8 of Miller and Rollnick 

2002, “Responding to Resistance” (pp. 

98–110). 

4. Supporting self-efficacy 

The final principle of Motivational Interviewing 

recognizes that an individual must believe he or 

she actually can make a change before attempting to do so. Therefore, the counselor offers 

support for the change and communicates to 

the client a strong sense that change is possible. 

Self-efficacy also can be enhanced through the 

use of peer role models, as well as by pointing 

out past and present evidence of the client’s 

capacity for change. 

One way practitioners put this principle into 

action is by evoking “confidence talk” in 

which the client is invited to share “ideas, 

experiences, and perceptions that are consistent with ability to change” (Miller and 

Rollnick 2002, p. 113). This could involve 

reviewing past successes, discussing specific 

steps for making change happen, identifying 

personal strengths, and acknowledging 

sources of support. 

“Change talk” 

Clients’ positive remarks about change, or 

“change talk,” are the opposite of resistance. 

The counselor responds to any expression of 

desire to change with interest and encourages 

the client to elaborate on the statement. For 

example in a person with combined alcohol 

dependence and PTSD, the clinician might ask, 

“What are some other reasons why you might 

want to make a change?” (Miller and Rollnick 

2002, p. 87). The counselor also can use reflec114 Keys to Successful Programming 
tive listening to clarify the client’s meaning and 

explore what is being said. It is important, 

however, to do this in a way that does not 

appear to be taking a side in the argument. 

This sometimes results in resistance and the 

client may begin to argue with the counselor 

instead of continuing to think about change. 

“Decisional balance” 

Practitioners of MI have coined the term “decisional balance” to describe a way of looking at 

ambivalence. Picture a seesaw, with the costs of 

the status quo and the benefits of change on 

one side, and the costs of change and the benefits of the status quo on the other (Miller and 

Rollnick 2002). The counselor’s role is to 

explore the costs and benefits of substance use 

with the aim of tipping the balance toward 

change. That change will be stronger and more 

likely to endure if it is owned by the client’s 

perception that the benefits of change are 

greater than the costs. 

Matching motivational 

strategies to the client’s 

stage of change 

The motivational strategies selected should be 

consistent with the client’s stage of change 

(summarized in Figure 5-1, p. 116). Clients 

could be at one stage of recovery or change 

for the mental disorder and another for the 

substance use disorder; to complicate things 

further, a client may be at one stage of change 

for one substance and another stage of change 

for another substance. For example, a client 

with combined alcohol and cocaine dependence with co-occurring panic disorder may 

be in the contemplation stage (i.e., aware that 

a problem exists and considering overcoming 

it, but not committed to taking action) in 

regard to alcohol, precontemplation (i.e., 

unaware that a problem exists, with no intention of changing behavior) in regard to 

cocaine, and action (i.e., actively modifying 

behavior, experiences, or environment to 

overcome the problem) for the panic 

disorder. 

In each case, the clinician examines the internal and external leverage available to move 

the client toward healthy change. For example, a client may want to talk about her marriage, but not about the substance abuse 

problem. The clinician can use this as an 

opening; the marriage doubtless will be affected by the substance abuse, and the motivation to improve the marriage may lead to a 

focus on substance abuse. Evaluating a 

client’s motivational state necessarily is an 

ongoing process. It should be recognized that 

court mandates, rules for clients engaged in 

group therapy, the treatment agency’s operating restrictions, or other factors may place 

some barriers on how this strategy is implemented in particular situations. 

Figure 5-2 (pp. 117–118) illustrates approaches that a clinician might use at different stages 

of readiness to change to apply MI techniques 

when working with a substance abuse client 

showing evidence of COD. For a thorough 

discussion of MI and the stages of change, the 

reader is referred to Miller and Rollnick 2002 

(pp. 201–216). 

Although MI is a well-accepted and commonly 

used strategy in the substance abuse treatment field, the issue of when it is appropriate 

to avoid or postpone addressing the client’s 

substance use is the subject of some debate. 

MI does make a distinction between agreeing 

with a client’s denial system (which is counterproductive) and sidestepping it in order to 

make some progress. As shown above, these 

motivational strategies are employed to help 

both clinician and client work together 

toward the common goal of helping the client. 

With practice and experience, the clinician 

will come to recognize when to sidestep disagreements and pursue MI and when to move 

forward with traditional methods with clients 

who are motivated sufficiently and ready for 

change. The details of these strategies and 

Strategies for Working With Clients With Co-Occurring Disorders 115 
Figure 5-1 

Stages of Change 

Source: Adapted from Prochaska et al. 1992. 

Stage Characteristics 

Precontemplation No intention to change in the foreseeable future; may be unaware or under-aware of 

problems. 

Contemplation Aware that a problem exists and thinking seriously about overcoming it, but have no 

commitment to take action yet made; weighing pros and cons of the problem and its 

solution. 

Preparation Combines intention and behavior—action is planned within the next month, and 

action has been taken unsuccessfully in the past year; some reductions have been 

made in problem behaviors, but a criterion for effective action has not been reached. 

Action Behavior, experiences, or environment are modified to overcome the problem; successful alteration of the addictive behavior for anywhere between 1 day to 6 months 

(note that action does not equal change). 

Maintenance Working to prevent relapse and consolidate gains attained during the Action stage; 

remaining free from addictive behavior and engaging consistently in a new incompatible behavior for more than 6 months. 

techniques are presented in TIP 35 (CSAT 

1999b) and in Miller and Rollnick 2002. 

Motivational interviewing 

and co-occurring disorders 

Approaches based on MI have been adapted 

for people with COD with some initial evidence 

of efficacy for improved treatment engagement. 

In a sample of 100 inpatient clients with COD 

from a large university hospital, Daley and 

Zuckoff (1998, p. 472) found that with only one 

“motivational therapy” session prior to hospital discharge, “...the show rate for the initial 

outpatient appointment almost doubled, 

increasing from 35 percent to 67 percent.” In 

this study MI approaches were modified to 

focus on contrasting the goals and methods of 

hospital and outpatient treatment. Also, the 

client was invited to consider the advantages 

and challenges of continuing in outpatient 

treatment. Daley and Zuckoff’s results are relevant for people in most quadrants (see chapters 

2 and 3), as the majority of their clientele are 

described as “public sector clients who have 

mood, anxiety, personality, or psychotic disorders combined with alcohol, cocaine, heroin, 

sedative hypnotic, cannabis, or polysubstance 

use disorders.” 

Swanson and colleagues (1999) modified MI 

techniques by increasing the amount of discussion of the client’s perception of the problem and his understanding of his clinical condition. Of the 121 study participants who 

were selected from psychiatric inpatients at 

two inner-city hospitals, 93 had concomitant 

substance use disorders. Participants were 

assigned randomly to either standard treatment or standard treatment with the addition 

of a motivational interview. The MI focused 

on exploring the clients’ commitment to treatment, plans for continuing care, and understanding of their role in their own recovery. 

116 Strategies for Working With Clients With Co-Occurring Disorders 
Essentially, the therapists were attempting to 

elicit a motivational statement that indicated 

the clients’ commitment to treatment. The 

authors found that, whether considering the 

entire sample or only those with COD, study 

participants who received the MI were significantly more likely to attend an initial outpatient treatment session. 

Motivational strategies have been shown to be 

helpful with persons who have serious mental 

disorders. Most programs designed for persons with such disorders recognize “that the 

majority of psychiatric clients have little 

readiness for abstinence-oriented substance 

use disorder (SUD) treatments;” therefore, 

they “incorporate motivational interventions 

designed to help clients who either do not recFigure 5-2 

Motivational Enhancement Approaches 

Stage of Readiness Motivational Enhancement Approaches 

Precontemplation •

• 

•

• 

• 

• 

•

Express concern about the client’s substance use, or the client’s mood, anxiety, or 

other symptoms of mental disorder. 

State nonjudgmentally that substance use (or mood, anxiety, self-destructiveness) is a 

problem. 

Agree to disagree about the severity of either the substance use or the psychological 

issues. 

Consider a trial of abstinence to clarify the issue, after which psychological evaluation 

can be reconsidered. 

Suggest bringing a family member to an appointment. 

Explore the client’s perception of a substance use or psychiatric problem. 

Emphasize the importance of seeing the client again and that you will try to help. 

Contemplation • 

• 

• 

• 

•

Elicit positive and negative aspects of substance use or psychological symptoms. 

Ask about positive and negative aspects of past periods of abstinence and substance 

use, as well as periods of depression, hypomania, etc. 

Summarize the client’s comments on substance use, abstinence, and psychological 

issues. 

Make explicit discrepancies between values and actions. 

Consider a trial of abstinence and/or psychological evaluation. 

Preparation • 

• 

• 

• 

• 

•

Acknowledge the significance of the decision to seek treatment for one or more disorders. 

Support self-efficacy with regard to each of the COD. 

Affirm the client’s ability to seek treatment successfully for each of the COD. 

Help the client decide on appropriate, achievable action for each of the COD. 

Caution that the road ahead is tough but very important. 

Explain that relapse should not disrupt the client–clinician relationship. 

Strategies for Working With Clients With Co-Occurring Disorders 117 
Figure 5-2 (continued) 

Motivational Enhancement Approaches 

Stage of Readiness Motivational Enhancement Approaches 

Action • 

•

•

Be a source of encouragement and support; remember that the client may be in the 

action stage with respect to one disorder but only in contemplation with respect to 

another; adapt your interview approach accordingly. 

 Acknowledge the uncomfortable aspects of withdrawal and/or psychological symptoms. 

Reinforce the importance of remaining in recovery from both problems. 

Maintenance • 

• 

• 

•

Anticipate and address difficulties as a means of relapse prevention. 

Recognize the client’s struggle with either or both problems, working with separate 

mental health and substance abuse treatment systems, and so on. 

Support the client’s resolve. 

Reiterate that relapse or psychological symptoms should not disrupt the counseling 

relationship. 

Relapse • 

• 

• 

•

Explore what can be learned from the relapse, whether substance-related or related to 

the mental disorder. 

Express concern and even disappointment about the relapse. 

Emphasize the positive aspect of the effort to seek care. 

Support the client’s self-efficacy so that recovery seems achievable. 

Source: Reproduced from Samet et al. 1996 (used with permission). 

ognize their SUD or do not desire substance 

abuse treatment to become ready for more 

definitive interventions aimed at abstinence” 

(Drake and Mueser 2000). 

A four-session intervention has been developed specifically to enhance readiness for 

change and treatment engagement of persons 

with schizophrenia who also abuse alcohol 

and other substances (Carey et al. 2001). This 

intervention is summarized in Figure 5-3 

(p. 119). In a pilot study of the intervention, 

92 percent of the 22 participants completed 

the series of sessions, all of whom reported 

that intervention was both positive and helpful. A range of motivational variables showed 

post-intervention improvements in recognition of substance use problems and greater 

treatment engagement, confirmed by independent clinician ratings. Those who began the 

intervention with low problem recognition 

made gains in that area; those who began with 

greater problem recognition made gains in the 

frequency of use and/or involvement in treatment. Although these data are preliminary, 

the technique is well articulated. It shows 

promise and warrants further research, 

including efforts to determine its efficacy 

among clients with COD who have mental disorders other than schizophrenia. 

It should be noted, however, that assessment 

of readiness to change could differ markedly 

between the client and the clinician. 

Addington et al. (1999) found little agreement 

between self-report of stage of readiness to 

118 Strategies for Working With Clients With Co-Occurring Disorders 
change and the assessment of stage of readiness determined by interviewers for their 39 

outpatients with diagnoses of both schizophrenia and a substance use disorder. In view 

of these observations, clinicians should be 

careful to establish a mutual agreement on 

the issue of readiness to change with their 

clients. 

Applying the motivational 

interviewing approach to 

clients with COD 

To date, motivational interviewing strategies 

have been applied successfully to the treatment 

of clients with COD, especially in 

• Assessing the client’s perception of the 

problem 

• Exploring the client’s understanding of his or 

her clinical condition 

Figure 5-3 

A Four-Session Motivation-Based Intervention 

Session 1—Introduction, Assessment, and Information Feedback 

Goals Therapeutic Activities Purpose 

Establish therapeutic alliance and collaborative 

approach 

Begin to develop 

discrepancy (raise 

awareness of the 

extent of use and 

negative consequences) 

Introduce intervention •

•

To elicit reasons and motivations for attending 

To establish understanding of the nature and purpose 

of the intervention 

Assess and discuss readiness to change • 

• 

• 

To establish mutual understanding of attitudes toward 

substance use and prospects for change 

To convey respect for the client’s attitudes 

To evaluate using open-ended and structured techniques 

Feedback of current use, 

consequences, and risks 

•To foster client’s awareness of extent of use, comparison 

to norms, negative consequences, and risks of pattern of 

use 

Session 2—Decisional Balance 

Goals Therapeutic Activities Purpose 

Continue emphasis 

on therapeutic 

alliance and collaborative approach 

Place more emphasis on developing 

discrepancy 

Review Session 1 and 

introduce Session 2 

•

•

To let the client know what to expect (alleviates anxiety) 

To help the client remember insights/reactions to reinforce gains 

Decisional balance • 

• 

To help the client identify and verbalize salient cons of 

using and pros of quitting 

To foster dissatisfaction with use, and interest in quitting, clarifying barriers to change 

Strategies for Working With Clients With Co-Occurring Disorders 119 
Figure 5­3 (continued)

A Four­Session Motivation­Based Intervention

Source: Carey et al. 2001.

Session 3—Strivings and Efficacy

Goals Therapeutic Activities Purpose

Continue emphasis

on developing discrepancy

Place more emphasis on self­efficacy

Review Session 2 and

introduce Session 3

•To reorient the client to the treatment process and

reinforce past gains

Assess and discuss

expectancies with regard

to behavior change

•

•

To monitor changes in perceived importance and selfefficacy to change substance use

To shore up motivation for change or address reasons for

low motivation

Strivings list •To develop discrepancy between a future with and without change in substance use by verbalizing personal aspirations, likely negative effects of use to achieving goals,

and potential facilitative effects of abstinence

Session 4—Goals and Action Plan

Goals Therapeutic Activities Purpose

Reinforce motivational gains (in perceived importance

of change, self­efficacy)

To leave the client

with a clear plan of

action

Review treatment •

•

•

To reinforce motivational changes

To extend the principle of providing periodic summaries

of discussion throughout the course of each session

To use repetition to compensate for deficits in attention

and memory

Elicit goals and develop

written plan of action

•

•

•

To help identify and clarify specific, realistic goals

around substance use reduction

To help develop a plan of action, including mobilizing

external supports and internal resources

To help the client anticipate barriers and solve problems

around him

120 Strategies for Working With Clients With Co­Occurring Disorders
•Examining the client’s desire for continued 

treatment 

•Ensuring client attendance at initial sessions 

•Expanding the client’s assumption of responsibility for change 

Future directions include 

•Further modification of MI protocols to make 

them more suitable for clients with COD, 

particularly those with serious mental disorders 

•Tailoring and combining MI techniques with 

other treatments to solve the problems (e.g., 

engagement, retention, etc.) of all treatment 

modalities 

See the text box below for a case study applying MET. 

Design Contingency 

Management Techniques To 

Address Specific Target 

Behaviors 

Description 

Contingency Management (CM) maintains that 

the form or frequency of behavior can be 

altered through a planned and organized system of positive and negative consequences. CM 

Case Study: Using MET With a Client Who Has COD 

Gloria M. is a 34-year-old African-American female with a 10-year history of alcohol dependence and 12-year 

history of bipolar disorder. She has been hospitalized previously both for her mental disorder and for substance abuse treatment. She has been referred to the outpatient substance abuse treatment provider from 

inpatient substance abuse treatment services after a severe alcohol relapse. 

Over the years, she sometimes has denied the seriousness of both her addiction and mental disorders. 

Currently, she is psychiatrically stable and is prescribed valproic acid to control the bipolar disorder. She 

has been sober for 1 month. 

At her first meeting with Gloria M., the substance abuse treatment counselor senses that she is not sure 

where to focus her recovery efforts—on her mental disorders or her addiction. Both have led to hospitalization and to many life problems in the past. Using motivational strategies, the counselor first attempts to find 

out Gloria M.’s own evaluation of the severity of each disorder and its consequences to determine her stage of 

change in regard to each one. 

Gloria M. reveals that while in complete acceptance and an active stage of change around alcohol dependence, she is starting to believe that if she just goes to enough recovery meetings she will not need her bipolar 

medication. Noting her ambivalence, the counselor gently explores whether medications have been stopped in 

the past and, if so, what the consequences have been. Gloria M. recalls that she stopped taking medications 

on at least half a dozen occasions over the last 10 years; usually, this led her to jail, the emergency room, or a 

period of psychiatric hospitalization. The counselor explores these times, asking: Were you feeling then as 

you were now—that you could get along? How did that work out? Gloria M. remembers believing that if she 

attended 12-Step meetings and prayed she would not be sick. In response to the counselor’s questions, she 

observes, “I guess it hasn’t ever really worked in the past.” 

The counselor then works with Gloria M. to identify the best strategies she has used for dual recovery in the 

past. “Has there been a time you really got stable with both disorders?” Gloria M. recalls a 3-year period 

between the ages of 25 and 28 when she was stable, even holding a job as a waitress for most of that period. 

During that time, she recalls, she saw a psychiatrist at a local mental health center, took medications regularly, and attended AA meetings frequently. She recalls her sponsor as being supportive and helpful. The counselor then affirms the importance of this period of success and helps Gloria M. plan ways to use the strategies 

that have already worked for her to maintain recovery in the present. 

Strategies for Working With Clients With Co-Occurring Disorders 121 
assumes that neurobiological and environmental factors influence substance use behaviors 

and that the consistent application of reinforcing environmental consequences can change 

these behaviors. CM principles for substance 

abuse treatment have been structured around 

four central principles (Higgins and Petry 

1999): 

• The clinician arranges for regular drug testing to ensure the client’s use of the targeted 

substance is detected readily. 

• The clinician provides positive reinforcement 

when abstinence is demonstrated. These positive reinforcers are agreed on mutually. 

• The clinician withholds the designated incentives from the individual when the substance 

is detected. 

• The clinician helps the client establish alternate and healthier activities. 

CM techniques are best applied to specific targeted behaviors such as 

•Drug abstinence 

•Clinic attendance and group participation 

•Medication adherence 

•Following treatment plan 

•Attaining particular goals 

The clinician may use a variety of CM techniques or reinforcers. The most common are 

•Cash 

•Vouchers 

•Prizes 

•Retail items 

•Privileges 

Figure 5-4 contains a checklist for a clinician 

designing CM programs. See also p. 124 for a 

case study applying CM. 

Empirical evidence on the 

effectiveness of contingency 

management 

A substantial empirical base supports CM techniques, which have been applied effectively to a 

variety of behaviors. CM techniques have 

demonstrated effectiveness in enhancing retention and confronting drug use (e.g., Higgins 

1999; Petry et al. 2000). The techniques have 

been shown to address use of a variety of specific substances, including opioids (e.g., Higgins 

et al. 1986; Magura et al. 1998), marijuana 

(Budney et al. 1991), alcohol (e.g., Petry et al. 

2000), and a variety of other drugs including 

cocaine (Budney and Higgins 1998). However, 

CM techniques have not been implemented in 

community-based settings until recently. The 

use of vouchers and other reinforcers has considerable empirical support (e.g., Higgins 1999; 

Silverman et al. 2001), but little evidence is 

apparent for the relative efficacy of different 

reinforcers. The effectiveness of CM principles 

when applied in community-based treatment 

settings and specifically with clients who have 

COD remains to be demonstrated. 

Some examples of the use of CM techniques 

have direct implications for people with COD: 

•Housing and employment contingent on 

abstinence. CM, where housing and employment are contingent on abstinence, has 

been used and studied among populations 

of homeless persons, many with COD 

(Milby et al. 1996; Schumacher et al. 1995). 

Results show that participants in treatment 

with contingencies were more likely than 

those in conventional treatment to test clean 

for drugs, to move into stable housing, and 

to gain regular employment following treatment. 

•Managing benefits and establishing representative payeeships. Procedures have been 

established to manage benefits for persons 

with serious mental illness and substance 

use disorders (Ries and Comtois 1997) and 

for establishing representative payeeships 

for clients with COD that involve managing 

money and other benefits (e.g., Conrad et 

al. 1999). In these approaches, once abstinence is achieved, clients are allowed 

greater latitude for management of their 

own finances. 

•A token economy for homeless clients with 

COD. A token economy has been developed 

with clients with COD in a shelter to provide immediate and systematic reinforce122 Strategies for Working With Clients With Co-Occurring Disorders 
Figure 5-4 

Checklist for Designing CM Programs 

Source: Petry 2000a. 

Step Description 

1. Choose a behavior • 

• 

One that is objectively quantifiable, occurs frequently, and is considered to be 

most important. 

Set reasonable expectations. 

2. Choose a reinforcer • 

• 

Determine available resources (in-house rewards or donations of cash or services 

from local businesses such as movie theaters and restaurants). 

Identify intangible rewards, such as frequent positive reports to parole officers, 

flexibility in methadone dosing, and increased freedom (smoke breaks, passes, 

etc.). 

3. Use behavioral 

principles 

• 

•

Develop a monitoring and reinforcement schedule that is optimized through 

application of behavioral principles. 

Keep the schedule simple so staff can apply principles consistently and clients can 

understand what is expected. 

4. Prepare a behavioral 

contract 

• 

•

• 

Draw up a contract for the target behavior that considers the monitoring system 

and reinforcement schedule. 

Be specific and consider alternate interpretations; have others review the contract and comment. 

Include any time limitations. 

5. Implement the 

contract 

• 

• 

Ensure consistent application of the contract; devise methods of seeing that staff 

understands and follows procedures. 

Remind the client of behaviors and their consequences (their “account balance” 

and what is required to obtain a bonus) to increase the probability that the escalating reward system will have the desired effect. 

ment for an array of behaviors during the 

engagement phase. Points were awarded for 

the successful accomplishment of a standard list of behaviors essential to the development of commitment, such as medication 

adherence, abstinence, attendance at program activities, and followthrough on referrals. Points were tallied weekly and tangible 

rewards (phone cards, treats, toiletries, 

etc.) were distributed commensurate with 

the earned point totals (Sacks et al. 2002). 

Awareness of the principles of CM can help the 

clinician to focus on quantifiable behaviors that 

occur with a good deal of frequency and to provide the reinforcers in an immediate and consistent fashion. CM principles and methods can 

be accommodated flexibly and applied to a 

range of new situations that can increase clinician effectiveness. It should be noted that many 

counselors and programs employ CM principles 

informally when they praise or reward particular behaviors and accomplishments and that 

even formal use of CM principles are found in 

Strategies for Working With Clients With Co-Occurring Disorders 123 
Case Study: Using CM With a Client With COD 

Initial Assessment 

Mary A. is a 45-year-old Caucasian woman diagnosed with heroin and cocaine dependence, depression, antisocial personality disorder, and cocaine-induced psychotic episodes. She has a long history of prostitution and 

sharing injection equipment. She contracted HIV 5 years ago. 

Mary A. had been on a regimen of methadone maintenance for about 2 years. Despite dose increases up to 120 

mg/day, she continued using heroin at the rate of 1 to 15 bags per day as well as up to 3 to 4 dime bags per day 

of cocaine. After cessation of a cocaine run, Mary A. experienced tactile and visual hallucinations characterized by “bugs crawling around in my skin.” She mutilated herself during severe episodes and brought in some 

of the removed skin to show the “bugs” to her therapist. 

Mary A. had been hospitalized four times for cocaine-induced psychotic episodes. Following an 11-day stay in 

an inpatient dual diagnosis program subsequent to another cocaine-induced psychotic episode, Mary A. was 

referred to an ongoing study of contingency management interventions for methadone-maintained, cocainedependent outpatients. 

Behaviors To Target 

Mary A.’s primary problem was her drug use, which was associated with cocaine-induced psychosis and an 

inability to adhere to a regimen of psychiatric medications and methadone. Because her opioid and cocaine use 

were linked intricately, it was thought that a CM intervention that targeted abstinence from both drugs would 

improve her functioning. As she was already maintained on a high methadone dose, methadone dose adjustments were not made. 

CM Plan 

Following discharge from the psychiatric unit, Mary A. was offered participation in a NIDA-funded study evaluating lower-cost contingency management treatment (e.g., Petry et al. 2000, pp. 250–257) for cocaine-abusing 

methadone clients. As part of participation in this study, Mary A. agreed to submit staff-observed urine samples on 2 to 3 randomly selected days each week for 12 weeks. She was told that she had a 50 percent chance of 

receiving standard methadone treatment plus frequent urine sample testing of standard treatment along with a 

contingency management intervention. She provided written informed consent, as approved by the 

University’s Institutional Review Board. 

Mary A. was assigned randomly to the CM condition. In this condition, she earned one draw from a bowl for 

every urine specimen that she submitted that was clean from cocaine or opioids and four draws for every specimen that was clean from both substances. The bowl contained 250 slips of paper. Half of them said “Good job” 

but did not result in a prize. Other slips stated “small prize” (N=109), “large prize” (N=15), or “jumbo prize” 

(N=1). Slips were replaced after each drawing so that probabilities remained constant. A lockable prize cabinet 

was kept onsite in which a variety of small prizes (e.g., socks, lipstick, nail polish, bus tokens, $1 gift certificates to local fast-food restaurants, and food items), large prizes (sweatshirts, portable CD players, watches, 

and gift certificates to book and record stores), and jumbo prizes (VCRs, televisions, and boom boxes) were 

kept. When a prize slip was drawn, Mary A. could choose from items available in that category. All prizes were 

purchased through funds from the research grant. 

In addition to the draws from the bowl for clean urine specimens, for each week of consecutive abstinence from 

both cocaine and opioids Mary A. earned bonus draws. The first week of consecutive cocaine and opioid abstinence resulted in five bonus draws, the second week resulted in six bonus draws, the third week seven and so 

on. In total, Mary A. could earn about 200 draws if she maintained abstinence throughout the 12-week study. 

124 Strategies for Working With Clients With Co-Occurring Disorders 
Clinical Course 

Mary A. earned 175 draws during treatment, receiving prizes purchased for a total of $309. She never 

missed a day of methadone treatment, attended group sessions regularly, and honored all her individual 

counseling sessions at the clinic. At 6-month follow-up, she had experienced only one drug use lapse, 

which she self-reported. Her depression cleared with her abstinence, and so did her antisocial behavior. 

She was pleased with the prizes and stated, “Having good stuff in my apartment and new clothes makes 

me feel better about myself. When I feel good about me, I don’t want to use cocaine.” 

Source: Adapted from Petry et al. 2001b. 

programs where attainment of certain levels 

and privileges are contingent on meeting certain behavioral criteria. 

Use Cognitive–Behavioral 

Therapeutic Techniques 	 

Description 

Cognitive–behavioral therapy (CBT) is a therapeutic approach that seeks to modify negative or self-defeating thoughts and behavior. 

CBT is aimed at both thought and behavior 

change (i.e., coping by thinking differently 

and coping by acting differently). One cognitive technique is known as “cognitive restructuring.” For example, a client may think initially, “The only time I feel comfortable is 

when I’m high,” and learn through the counseling process to think instead, “It’s hard to 

learn to be comfortable socially without doing 

drugs, but people do so all the time” (TIP 34, 

Brief Interventions and Brief Therapies for 

Substance Abuse [CSAT 1999a], pp. 64–65). 

CBT includes a focus on overt, observable 

behaviors—such as the act of taking a drug— 

and identifies steps to avoid situations that

lead to drug taking. CBT also explores the 

interaction among beliefs, values, perceptions, expectations, and the client’s explanations for why events occurred.

An underlying assumption of CBT is that the 

client systematically and negatively distorts 

her view of the self, the environment, and the 

future (O’Connell 1998). Therefore, a major 

tenet of CBT is that the person’s thinking is 

the source of difficulty and that this distorted 

thinking creates behavioral problems. CBT 

approaches use cognitive and/or behavioral 

strategies to identify and replace irrational 

beliefs with rational beliefs. At the same time, 

the approach prescribes new behaviors the 

client practices. These approaches are educational in nature, active and problem-focused, 

and time-limited. 

Advice to the Counselor: 

Using Contingency Management 

Techniques 

The consensus panel recommends that substance 

abuse treatment clinicians and programs employ CM 

techniques with clients with COD in such activities as 

• 

• 

• 

• 

• 

Providing refreshments for attendance at groups or		

social activities 

Monitoring urine specimens		

Checking medication adherence 

Rewarding clients for obtaining particular goals in 

their treatment plan 

Reinforcing appropriate verbal and social behavior 

CBT for substance abuse 

CBT for substance abuse combines elements of behavioral theory, cognitive 

social learning theory, cognitive theory, 

and therapy into a distinctive therapeutic

approach that helps clients recognize situations where they are likely to use substances, find ways of avoiding those situations, and learn better ways to cope with 

feelings and situations that might have, in

the past, led to substance use (Carroll

1998).

Strategies for Working With Clients With Co-Occurring Disorders 125 
CBT for people with substance use disorders 

also addresses “coping behaviors.” Coping 

“refers to what an individual does or thinks 

in a relapse crisis situation so as to handle the 

risk for renewed substance use” (Moser and 

Annis 1996, p. 1101). The approach assumes 

that “substance abusers are deficient in their 

ability to cope with interpersonal, social, 

emotional, and personal problems. In the 

absence of these skills, such problems are 

viewed as threatening, stressful, and potentially unsolvable. Based on the individual’s 

observation of both family members’ and 

peers’ responses to similar situations and on 

their own initial experimental use of alcohol 

or drugs, the individual uses substances as a 

means of trying to address these problems 

and the emotional reactions they create” 

(CSAT 1999a, p. 71). The clinician seeks to 

help the client increase his coping skills so he 

will not use drugs in high-stress situations. 

(See TIP 34 [CSAT 1999a] for a more 

detailed explanation of the theoretical background of CBT and how it is applied in substance abuse treatment.) 

CBT and COD 

Distortions in thinking generally are more 

severe with people with COD than with other 

substance abuse treatment clients. For example, a person with depression and an alcohol 

use disorder who has had a bad reaction to a 

particular antidepressant may claim that all 

antidepressant medication is bad and must be 

avoided at all costs. Likewise, individuals may 

use magnification and minimization to exaggerate the qualities of others, consistently presenting themselves as “losers” who are incapable of 

accomplishing anything. Clients with COD are, 

by definition, in need of better coping skills. 

The Substance Abuse Management Model in 

the section on Relapse Prevention Therapy 

later in this chapter provides a pertinent example of how to increase behavioral coping skills. 

Grounding 

Some clients with COD, such as those who have 

experienced trauma or sexual abuse, can benefit from a particular coping skill known as 

“grounding” (Najavits 2002). Many such clients 

frequently experience overwhelming feelings 

linked to past trauma, which can be triggered 

by a seemingly small comment or event. 

Sometimes, this sets off a craving to use substances. Grounding refers to the use of strategies that soothe and distract the client who is 

experiencing tidal waves of pain or other strong 

emotions, helping the individual anchor in the 

present and in reality. These techniques work 

by directing the mental focus outward to the 

external world, rather than inward toward the 

self. Grounding also can be referred to as “centering,” “looking outward,” “distraction,” or 

“healthy detachment” (Najavits 2002). 

Grounding “can be done anytime, anywhere, 

by oneself, without anyone else noticing it. It 

can also be used by a supportive friend or 

partner who can guide the patient in it when 

the need arises” (Najavits 2002, p. 125). It is 

used commonly for PTSD, but can be applied 

to substance abuse cravings, or any other 

intense negative feeling, such as anxiety, panic 

attacks, and rage. Grounding is so basic and 

simple that it gives even the most impaired 

clients a useful strategy. However, it must be 

practiced frequently to be maximally helpful. 

For a lesson plan and other materials on 

grounding, see Najavits 2002. See also the section on PTSD in chapter 8 and appendix D of 

this TIP. 

Roles of the client and 

clinician 

CBT is an active approach that works most 

effectively with persons who are stabilized in 

the acute phase of their substance use and 

mental disorders. To be effective, the clinician 

and the client must develop rapport and a 

working alliance. The client’s problem is 

assessed extensively and thorough historical 

data are collected. Then, collaboratively, dysfunctional automatic thoughts, schemas, and 

cognitive distortions are identified. Treatment 

consists of the practice of adaptive skills within 

the therapeutic environment and in homework 

sessions. Booster sessions are used following 

126 Strategies for Working With Clients With Co-Occurring Disorders 
Case Study: Using CBT With a Client With COD 

Jack W. is referred to the substance abuse treatment agency for evaluation after a positive urine test that 

revealed the presence of cocaine. He is a 38-year-old African American. Initially, Jack W. engages in treatment 

in intensive outpatient therapy three times weekly, has clean urine tests, and seems to be doing well. However, 

after 2 months he starts to appear more depressed, has less to say in group therapy sessions, and appears withdrawn. In a private session with the substance abuse treatment counselor, he says that, “All this effort just 

isn’t worth it. I feel worse than I did when I started. I might as well quit treatment and forget the job. What’s 

the point?” The counselor explores what has changed, and Jack W. reveals that his wife has been having a 

hard time interacting with him as a sober person. Now that he is around the house more than he used to be (he 

was away frequently, dealing drugs to support his habit), they have more arguments. He feels defeated. 

In the vocabulary of CBT, Jack W. demonstrates “all or nothing” thinking (I might as well lose everything 

because I’m having arguments), overgeneralization, and discounting the positive (he is ignoring the fact that he 

still has his job, has been clean for 2 months, looks healthier and, until recently, had an improved outlook). 

His emotionally clouded reasoning is blackening the whole recovery effort, as he personalizes the blame for 

what he sees as failure to improve his life. 

Clearly, Jack W. has lost perspective and seems lost in an apparently overwhelming marital problem. The 

counselor, using a pad and pencil, draws a circle representing the client and divides it into parts, showing Jack 

that they represent physical health, his work life, his recovery, risk for legal problems, and family or marriage. He invites Jack to review each one, comparing where he is now and where he was when he first arrived 

at the clinic in order to evaluate the whole picture. Jack observes that everything is actually getting better with 

the exception of his marriage. The counselor helps Jack gain the skills needed to stand back from his situation 

and put a problem in perspective. He also negotiates to determine the kind of help that Jack would see as useful in his marriage. This might be counseling for the couple or an opportunity to practice and rehearse ways of 

engaging his wife without either of them becoming enraged. 

If Jack’s depression continues despite these interventions, the counselor may refer him to a mental health 

provider for evaluation and treatment of depression. 

termination of treatment to assist people who 

have returned to old maladaptive patterns of 

thinking. 

The client with COD is an active participant in 

treatment, while the role of the clinician is primarily that of educator. The clinician collaborates with the client or group in identifying 

goals and setting an agenda for each session. 

The counselor also guides the client by explaining how thinking affects mood and behavior. 

Clients with COD may need very specific coping skills to overcome the combined challenges 

of their substance abuse and their mental disorder. For example, Ziedonis and Wyatt (1998, 

p. 1020) address the need to target “the 

schizophrenic’s cognitive difficulties (attention 

span, reading skills, and ability to abstract).” 

Their approach for these clients includes roleplaying to help build communication and problemsolving skills. 

Some specific CBT strategies for programs 

working with clients with COD are described 

below. See also the text box above for a case 

example. 

Use Relapse Prevention 

Techniques 

Description 

Marlatt defines relapse as “a breakdown or setback in a person’s attempt to change or modify 

any target behavior” (1985, p. 3). NIDA elaborates this definition by describing relapse as 

“any occasion of drug use by recovering 

Strategies for Working With Clients With Co-Occurring Disorders 127 
Adapting CBT for Clients With COD 

Source: Adapted from Peters and Hills 1997. 

•Use visual aids, including illustrations and concept mapping (a visual presentation of concepts that makes 

patterns evident). 

•Practice role preparation and rehearse for unexpected circumstances. 

•Provide specific in vivo feedback on applying principles and techniques. 

•Use outlines for all sessions that list specific behaviorally anchored learning objectives. 

•Test for knowledge acquisition. 

•Make use of memory enhancement aids, including notes, tapes, and mnemonic devices. 

addicts that violates their own prior commitment and that often they regret almost immediately” (NIDA 1993, p. 139), and adds Relapse 

Prevention Therapy (RPT) to its list of effective substance abuse treatment approaches. 

Relapse can be understood not only as the 

event of resuming substance use, but also as a 

process in which indicators of increasing 

relapse risk can be observed prior to an 

episode of substance use, or lapse (Daley 1987; 

Daley and Marlatt 1992). 

A variety of relapse prevention models are 

described in the literature (e.g., Gorski 2000; 

Marlatt et al. 1999; Monti et al. 1993; NIDA 

1993; Rawson et al. 1993). However, a central 

element of all clinical approaches to relapse 

prevention is anticipating problems that are 

likely to arise in maintaining change and 

labeling them as high-risk situations for 

resumed substance use, then helping clients to 

develop effective strategies to cope with those 

high-risk situations without having a lapse. A 

key factor in preventing relapse is to understand that relapses are preceded by triggers 

or cues that signal that trouble is brewing and 

that these triggers precede exposure to events 

or internal processes (high-risk situations) 

where or when resumed substance use is likely to occur. A lapse will occur in response to 

these high-risk situations unless effective coping strategies are available to the person and 

are implemented quickly and performed adequately. Clinicians using relapse prevention 

techniques recognize that lapses (single 

episodes or brief returns to drug use) are an 

expected part of overcoming a drug problem, 

rather than a signal of failure and an indication that all treatment progress has been lost. 

Therapy sessions aimed at relapse prevention 

can occur individually or in small groups, 

and may include practice or role-play on how 

to cope effectively with high-risk situations. 

According to Daley and Marlatt (1992), 

approaches to relapse prevention have many 

common elements. Generally they focus on 

the need for clients to 

1. Have a broad repertoire of cognitive and 

behavioral coping strategies to handle highrisk situations and relapse warning signs. 

2. Make lifestyle changes that decrease the 

need for alcohol, drugs, or tobacco. 

3. Increase healthy activities. 

4. Prepare for interrupting lapses, so that they 

do not end in full-blown relapse. 

5. Resume or continue to practice relapse prevention skills even when a full-blown relapse 

does occur by renewing their commitment to 

abstinence rather than giving up the goal of 

living a drug-free life. 

RPT is an intervention designed to teach individuals who are trying to maintain health 

behavior changes how to anticipate and cope 

with the problem of relapse (Marlatt 1985). 

RPT strategies can be placed in five categories: Assessment Procedures, Insight/ 

Awareness Raising Techniques, Coping Skills 

128 Strategies for Working With Clients With Co-Occurring Disorders 
Training, Cognitive Strategies, and Lifestyle 

Modification (Marlatt 1985). RPT Assessment 

Procedures are designed to help clients 

appreciate the nature of their problems in 

objective terms, to measure motivation for 

change, and to identify risk factors that 

increase the probability of relapse. 

Insight/Awareness Raising Techniques are 

designed to provide clients with alternative 

beliefs concerning the nature of the behavior 

change process (e.g., to view it as a learning 

process) and, through self-monitoring, to help 

clients identify patterns of emotion, thought, 

and behavior related to both substance use 

and co-occurring mental disorders. Coping 

Skills Training strategies include teaching 

clients behavioral and cognitive strategies. 

Cognitive Strategies are used to manage urges 

and craving, to identify early warning signals, 

and to reframe reactions to an initial lapse. 

Finally, Lifestyle Modification Strategies 

(e.g., meditation and exercise) are designed to 

strengthen clients’ overall coping capacity. 

In Marlatt’s model of RPT, lapses are seen as 

a “fork in the road” or a “crisis.” Each lapse 

contains the dual elements of “danger” (progression to full-blown relapse) and “opportunity” (reduced relapse risk in the future due 

to the lessons learned from debriefing the 

lapse). The goal of effective RPT is to teach 

clients to recognize increasing relapse risk 

and to intervene at earlier points in the 

relapse process in order to encourage clients 

to progress toward maintaining abstinence 

from drugs and living a life in which lapses 

occur less often and are less severe. 

Specific aspects of RPT might include 

•Exploring with the client both the positive 

and negative consequences of continued drug 

use (“decisional balance,” as discussed in the 

motivational interviewing section of this 

chapter) 

•Helping clients to recognize high-risk situations for returning to drug use 

•Helping clients to develop the skills to avoid 

those situations or cope effectively with them 

when they do occur 

• Developing a “relapse emergency plan” in 

order to exercise “damage control” to limit 

the duration and severity of lapses 

• Learning specific skills to identify and cope 

effectively with drug urges and craving 

Clients also are encouraged to begin the process of creating a more balanced lifestyle to 

manage their COD more effectively and to fulfill their needs without using drugs to cope with 

life’s demands and opportunities. In the treatment of clients with COD, it often is critical to 

consider adherence to a medical regimen 

required to manage disruptive and disorganizing symptoms of mental disorder as a relapse 

issue. In terms of medication adherence, a 

“lapse” is defined as not taking the prescribed 

drugs one needs rather than the resumption of 

taking illicit drugs for self-medication or pleasure seeking. 

Empirical evidence related to 

relapse prevention therapy 

Carroll (1996) reviewed 24 randomized controlled trials of RPT among smokers and 

abusers of alcohol, marijuana, cocaine, opioids, and other drugs. While many of the studies were of smokers—in which Carroll noted 

the strongest support for RPT in terms of 

improved outcomes for relapse severity, durability of effects, and client-treatment matching, 

as compared to no-treatment controls—comparable results were found for alcohol and illicit 

drugs as well. Of particular importance was the 

observation that the positive effects of RPT 

treatment were greater among those with higher severities of both psychiatric symptoms and 

addiction impairment, which suggests the technique would be helpful in the treatment of 

clients with COD. 

In a meta-analytic review of 26 published and 

unpublished studies using Marlatt’s RPT 

model, Irvin et al. (1999) found that RPT 

generally was effective particularly for alcohol problems and was most effective when 

applied to alcohol or polysubstance use disorders, combined with medication. The efficacy 

of RPT has been demonstrated sufficiently to 

Strategies for Working With Clients With Co-Occurring Disorders 129 
Advice to the Counselor: 

Using Relapse Prevention Methods 

The consensus panel recommends using the following 

relapse prevention methods with clients with COD: 

• Provide relapse prevention education on both mental 

disorders and substance abuse and their interrelations. 

• Teach skills to help the client handle pressure for discontinuing psychotropic medication and to increase medication adherence. 

• Encourage attendance at dual recovery groups and teach 

social skills necessary for participation. 

• Use daily inventory to monitor psychiatric symptoms and 

symptoms changes. 

• If relapse occurs, use it as a learning experience to 

investigate triggers with the client. Reframe the 

relapse as an opportunity for self-knowledge and a 

step toward ultimate success. 

be included by NIDA (1999a) as a recommended approach “to supplement or 

enhance—not replace—existing treatment 

programs” (p. 35). 

Adaptations for clients with 

COD 

Several groups have developed relapse prevention interventions aimed at clients with different mental disorders or substance use diagnoses (see Evans and Sullivan 2001). Weiss and 

colleagues (1998) developed a 20-session 

relapse prevention group therapy for the treatment of clients with co-occurring bipolar and 

substance use disorders. This group stressed 

concepts of importance to both disorders—for 

example, it contrasts “may as well” thinking, 

which allows for relapse and failure to take 

medication, with “it matters what you do.” It 

also teaches useful skills relevant to both disorders, such as coping with high-risk situations 

and modifying lifestyle to improve self-care (p. 

49). Ziedonis and Stern (2001) have developed 

a dual recovery therapy, which blends traditional mental health and addiction treatments 

(including both motivational enhancement therapy and relapse prevention) for clients with 

serious mental illness. Also, 

Nigam and colleagues (1992) 

developed a relapse prevention 

group for clients with COD. 

Substance abuse 

management module 

Roberts et al. (1999) developed 

The Substance Abuse 

Management Module (SAMM) 

based on the previously 

described RPT approach of 

Marlatt and his colleagues. 

SAMM originally was designed 

to be a component of a comprehensive approach to the treatment of co-occurring substance 

use dependence and schizophrenia. This detailed treatment 

manual illustrates many RPT 

techniques and focuses on the most common 

problems encountered by clients with severe 

COD. SAMM offers a detailed cognitive– 

behavioral strategy for each of several common problems that clients face. Each strategy 

includes both didactics and detailed skills 

training procedures including role-play practice. Emphasis is placed on rehearsing such 

key coping behaviors as refusing drugs, negotiating with treatment staff, acting appropriately at meetings for mutual self-help, and 

developing healthy habits. Both counselor 

and client manuals are available. 

The text box beginning on p. 131 describes the 

SAMM protocol (Roberts et al. 1999) shows 

how a clinician might work with a substance 

abuse treatment client with COD to help the 

client avoid drugs. 

Integrated treatment 

RPT (Marlatt and Gordon 1985) and other 

cognitive–behavioral approaches to psychotherapy and substance abuse treatment 

allow clinicians to treat COD in a integrated 

way by 

130 Strategies for Working With Clients With Co-Occurring Disorders 
Overview of SAMM Concepts and Skills 

How to Avoid Drugs (Made Simple) 

The concepts and skills taught in this module are designed to help clients follow these four recommendations: 

• 

• 

• 

• 

If you slip, quit early. 

When someone offers drugs, say no. 

Don’t get into situations where you can’t say no. 

Do things that are fun and healthy. 

Overview of Module Concepts and Skills 

Clients learn how to follow these recommendations by learning key concepts and the skills. Here are four recommendations restated in terms of the module’s key concepts: 

Plain English Module Concepts 

If you slip, quit early. Practice damage control. 

When someone offers drugs, say no. Escape high-risk situations. 

Don’t get into situations where you can’t say no. Avoid high-risk situations. 

Do things that are fun and healthy. Seek healthy pleasures. 

Concepts and Skills Associated With Each Recommendation 

Practice damage control 

Main point: If you slip and use drugs or alcohol again, stop early and get right back into treatment. This will 

reduce damage to your health, relationships, and finances. 

Concepts: Maintain recovery, slip versus full-blown relapse, risk reduction, abstinence violation effect, bouncing back into treatment. 

Skills: Leaving a drug-using situation despite some use; reporting a slip to a support person 

Escapehigh-risksituations

Main point: Some situations make it very hard to avoid using drugs. Be prepared to escape from these situations without using drugs. Realize that it would be much better to avoid these situations in the first place. 

Concepts: High-risk situations. 

Skills: Refusing drugs from a pushy dealer; refusing drugs offered by a friend. 

Strategies for Working With Clients With Co-Occurring Disorders 131 
Overview of SAMM Concepts and Skills (continued) 

Source: Adapted from Roberts et al. 1999 (used with permission). 

Avoid high-risk situations 

Main point: Avoid high-risk situations by learning to recognize the warning signs that you might be headed 

toward drug use. 

Concepts: Drug habit chain (trigger, craving, planning, getting, using), warning signs, U-turns, removing triggers, riding the wave, money management, representative payee. 

Skills: Getting an appointment with a busy person; reporting symptoms and side effects; getting a support 

person. 

Seek healthy pleasures 

Main point: You can avoid drugs by focusing on the things that are most important and enjoyable to you. Do 

things that are fun and healthy. 

Concepts: Healthy pleasures, healthy habits, activities schedule. 

Skills: Getting someone to join you in a healthy pleasure; negotiating with a representative payee. 

Additional Recommendations and Concepts 

Understand how you learned to use drugs. 

Main point: Drug abuse is learned and can be unlearned. 

Concepts: Habits, reinforcement, craving, conditioning, extinction, riding the wave. 

Know why you decided to quit. 

Main point: Make sure you can always remember why you decided to quit using drugs. 

Concepts: Advantages and disadvantages of using drugs and of not using drugs. 

Carry an emergency card. 

Main point: Make an emergency card that contains vital information and reminders about how and why to 

avoid drugs. Carry it with you at all times. 

Concepts: Support person, coping skills, why quit. 

1. Doing a detailed functional analysis of the 

relationships between substance use, Axis I 

or II symptoms, and any reported criminal 

conduct 

2. Evaluating the unique and common highrisk factors for each problem and determining their interrelationships 

3. Assessing both cognitive and behavioral coping skills deficits 

4. Implementing both cognitive and behavioral 

coping skills training tailored to meet the 

specific needs of an individual client with 

respect to all three target behaviors (i.e., 

substance use, symptoms of mental disorder, and criminal conduct) 

132 Strategies for Working With Clients With Co-Occurring Disorders 
Summary of RP strategies for 

clients with COD 

Daley and Lis (1995) summarize RP strategies 

that can be adapted for clients with COD, some 

of which are listed below: 

•Regardless of the client’s motivational level or 

recovery stage, relapse education should be 

provided and related to the individual’s mental disorder. The latter is important, particularly because the pattern typically followed 

by clients with COD begins with an increase 

in substance use leading to lowered efficacy 

or discontinuation of psychiatric medication, 

or missed counseling sessions. As a consequence, symptoms of mental disorders reappear or worsen, the client’s tendency to selfmedicate through substance use is exacerbated, and the downward spiral is perpetuated. 

•Clients with COD need effective strategies to 

cope with pressures to discontinue their prescribed psychiatric medication. One such 

strategy simply is to prepare clients for external pressure from other people to stop taking 

their medications. Rehearsing circumstances 

in which this type of pressure is applied, 

along with anticipating the possibility, 

enables clients with COD to react appropriately. Reinforcing the difference between 

substances of abuse—getting “high”—and 

taking psychiatric medication to treat an illness is another simple but effective strategy. 

•An integral component of recovery is the use 

of mutual self-help and dual recovery groups 

to provide the support and understanding of 

shared experience. To maximize the effectiveness of their participation, clients with COD 

usually need help with social skills (listening, 

self-disclosure, expressing feelings/desires, 

and addressing conflict). 

Clients can use daily self-ratings of persistent 

psychiatric symptoms to monitor their status. 

Use of the daily inventory and symptom review 

should be encouraged to help clients with COD 

to track changes and take action before deteriorating status becomes critical. See the text 

box on p. 134 for a case study applying RP 

strategies. 

Use Repetition and SkillsBuilding To Address Deficits in 

Functioning 

In applying the approaches described above, 

keep in mind that clients with COD often have 

cognitive limitations, including difficulty concentrating. Sometimes these limitations are 

transient and improve during the first several 

weeks of treatment; at other times, symptoms 

persist for long periods. In some cases, individuals with specific disorders (schizophrenia, 

attention deficit disorder) may manifest these 

symptoms as part of their disorder. 

General treatment strategies to address cognitive limitations in clients include being more 

concrete and less abstract in communicating 

ideas, using simpler concepts, having briefer 

discussions, and repeating the core concepts 

many times. In addition, individuals often 

learn and remember better if information is 

presented in multiple formats (verbally; visually; or affectively through stories, music, and 

experiential activities). Role-playing real-life 

situations also is a useful technique when working with clients with cognitive limitations. For 

example, a client might be assigned to practice 

“asking for help” phone calls using a prepared 

script. This can be done individually with the 

counselor coaching, or in a group, to obtain 

feedback from the members. 

When compared to individuals without additional disorders or disabilities, persons with 

COD and additional deficits often will require 

more substance abuse treatment in order to 

attain and maintain abstinence. A primary 

reason for this is that abstinence requires the 

development and utilization of a set of recovery skills, and persons with mental disorders 

often have a harder time learning new skills. 

They may require more support in smaller 

steps with more practice, rehearsal, and repetition. The challenge is not to provide more 

intensive or more complicated treatment for 

clients with COD, but rather to tailor the process of acquiring new skills to the needs and 

abilities of the client. 

Strategies for Working With Clients With Co-Occurring Disorders 133 
Case Study: Preventing Relapse in a Client With COD 

Source: Daley and Lis 1995, pp. 255–256. 

Stan Z. is a 32-year-old with diagnoses of recurrent major depression, antisocial personality disorder, 

crack/cocaine dependence, and polysubstance abuse. He has a 15-year history of addiction, including a 2-year 

history of crack addiction. Stan Z. has been in a variety of psychiatric and substance abuse treatment programs during the past 10 years. His longest clean time has been 14 months. He has been attending a dual-diagnosis outpatient clinic for the past 9 months and going to Narcotics Anonymous (NA) meetings off and on for 

several years. Stan Z. has been clean from all substances for 7 months. Following is a list of high-risk relapse 

factors and coping strategies identified by Stan Z. and his counselor: 

High-Risk Factor 1 

Stan Z. is tired and bored “with just working, staying at home and watching TV, or going to NA meetings.” 

Recently, he has been thinking about how much he “misses the action of the good old days” of hanging with 

old friends and does not think he has enough things to do that are interesting. 

Possible coping strategies for Stan Z. include the following: (1) remind him of problems caused by hanging 

out with people who use drugs and using drugs by writing out a specific list of problems associated with 

addiction; (2) challenge the notion of the “good old days” by looking closely at the “bad” aspects of those 

days; (3) remind him of how far he has come in his recent recovery, especially being able to get and keep a 

job, maintain a relationship with one woman, and stay out of trouble with the law; (4) discuss current feelings and struggles with an NA sponsor and NA friends to find out how they handled similar feelings and 

thoughts; and (5) make a list of activities that will not threaten recovery and can provide a sense of fun and 

excitement and plan to start active involvement in one of these activities. 

High-Risk Factor 2 

Stan Z. is getting bored with his relationship with his girlfriend. He feels she is too much of a “home body” 

and wants more excitement in his relationship with her. He also is having increased thoughts of having sex 

with other women. 

Possible coping strategies for Stan Z. include the following: (1) explore in therapy sessions why he is really 

feeling bored with his girlfriend, noting he has a long-standing pattern of dumping girlfriends after just a 

few months; (2) challenge his belief that the problem is mainly his girlfriend so that he sees how his attitudes and beliefs play a role in this problem; (3) talk directly with his girlfriend in a nonblaming fashion 

about his desire to work together to find ways to instill more excitement in the relationship; (4) remind him 

of potential dangers of casual sex with a woman he does not know very well and that he cannot reach his 

goal of maintaining a meaningful, mutual relationship if he gets involved sexually with another woman. His 

past history is concrete proof that such involvement always leads to sabotaging his primary relationship. 

High-Risk Factor 3 

Stan Z. wants to stop taking antidepressant medications. His mood has been good for several months and 

he does not see the need to continue medications. 

Possible coping strategies include the following: (1) discuss his concern about medications with his counselor and psychiatrist before making a final decision; (2) review with his treatment team the reasons for 

being on antidepressant medications; (3) remind him that because he had several episodes of depression, 

even during times when he has been drug-free for a long period, medication can help “prevent” the likelihood of a future episode of depression. 

134 Strategies for Working With Clients With Co-Occurring Disorders 
Case Study: Using Repetition and Skills Building With a 

Client With COD 

In individual counseling sessions with Susan H., a 34-year-old Caucasian woman with bipolar disorder and 

alcohol dependence, the counselor observes that often she is forgetful about details of her recent past, 

including what has been said and agreed to in therapy. Conclusions the counselor thought were clear in one 

session seem to be fuzzy by the next. The counselor begins to start sessions with a brief review of the last session. He also allows time at the end of each session to review what has just happened. As Susan H. is having 

difficulty remembering appointment times and other responsibilities, he helps her devise a system of 

reminders in big letters on her refrigerator. 

Facilitate Client Participation 

in Mutual Self-Help Groups 

Just as the strategies discussed in this chapter 

have proven helpful both to clients who have 

only substance use disorders as well as to those 

with COD, so the use of mutual self-help 

groups is a key tool for the clinician in assisting 

both categories of clients. In addition to traditional 12-Step groups, dual recovery mutual 

self-help approaches are becoming increasingly 

common in most large communities. The clinician plays an important role in helping clients 

with COD access appropriate mutual self-help 

resources and benefit from them. (See chapter 

7 for an extended presentation of Dual 

Recovery Mutual Self-Help approaches tailored to meet the needs of persons with COD.) 

Groups for those who do not speak English 

may not be available, and the clinician is 

advised to seek resources in other counties or, 

if the number of clients warrants it, to initiate 

organization of a group for those who speak the 

same non-English language. 

The clinician can assist the client by: 

•Helping the client locate an appropriate 

group. The clinician should strive to be 

aware not only of what local 12-Step and 

other dual recovery mutual self-help 

groups meet in the community, but also 

which 12-Step groups are known to be 

friendly to clients with COD, have other 

members with COD, or are designed specifically for people with COD. Clinicians do 

this by visiting groups to see how they are 

conducted, collaborating with colleagues to 

discuss groups in the area, updating their 

own lists of groups periodically, and gathering information from clients. The clinician 

should ensure that the group the client 

attends is a good fit for the client in terms 

of the age, gender, and cultural factors of 

the other members. In some communities, 

alternatives to 12-Step groups are available, 

such as Secular Organizations for Sobriety. 

Helping the client prepare to participate 

appropriately in the group. Some clients, 

particularly those with serious mental illness or anxiety about group participation, 

may need to have the group process 

explained ahead of time. Clients should be 

told the structure of a meeting, expectations 

of sharing, and how to participate in the 

closing exercises, which may include holding hands and repeating sayings or prayers. 

They may need to rehearse the kinds of 

things that are and are not appropriate to 

share at such meetings. Clients also should 

be taught how to “pass” and when this 

would be appropriate. The counselor 

should be familiar enough with group function and dynamics to actually “walk the 

•Helping the client find a sponsor, ideally 

one who also has COD and is at a later 

stage of recovery. Knowing that he or she 

has a sponsor who truly understands the 

impact of two or more disorders will be 

encouraging for the client. Also, some 

clients may “put people off” in a group and 

have particular difficulty finding a sponsor 

without the clinician’s support. 

•

Strategies for Working With Clients With Co-Occurring Disorders 135 
client” through the meeting before attending. 

•Helping overcome barriers to group participation. The clinician should be aware of the 

genuine difficulties a client may have in 

connecting with a group. While clients with 

COD, like any others, may have some resistance to change, they also may have legitimate barriers they cannot remove alone. 

For example, a client with cognitive difficulties may need help working out how he or 

she can physically get to the meeting. The 

counselor may need to write down very 

detailed instructions for this person that 

another client would not need (e.g., “Catch 

the number 9 bus on the other side of the 

street from the treatment center, get off at 

Main Street, and walk three blocks to the 

left to the white church. Walk in at the 

basement entrance and go to Room 5.”) 

•Debriefing with the client after he or she 

has attended a meeting to help process his 

or her reactions and prepare for future 

attendance. The clinician’s work does not 

end with referral to a mutual self-help 

group. The clinician must be prepared to 

help the client overcome any obstacles after 

attending the first group to ensure engagement in the group. Often this involves a discussion of the client’s reaction to the group 

and a clarification of how he or she can 

participate in future groups. 

Case Study: Helping a Client Find a Sponsor 

Linda C. had attended her 12-Step group for about 3 months, and although she knew she should ask someone 

to sponsor her, she was shy and afraid of rejection. She had identified a few women who might be good sponsors, but each week in therapy she stated that she was afraid to reach out, and no one had approached her, 

although the group members seemed “friendly enough.” The therapist suggested that Linda C. “share” at a 

meeting, simply stating that she’d like a sponsor but was feeling shy and didn’t want to be rejected. The therapist and Linda C. role-played together in a session, and the therapist reminded Linda C. that it was okay to 

feel afraid and if she couldn’t share at the next meeting, they would talk about what stopped her. 

After the next meeting, Linda C. related that she almost “shared” but got scared at the last minute, and 

was feeling bad that she had missed an opportunity. They talked about getting it over with, and Linda C. 

resolved to reach out, starting her sharing statement with, “It’s hard for me to talk in public, but I want 

to work this program, so I’m going to tell you all that I know it’s time to get a sponsor.” This therapy 

work helped Linda C. to put her need out to the group, and the response from group members was helpful 

to Linda C., with several women offering to meet with her to talk about sponsorship. This experience also 

helped Linda C. to become more attached to the group and to learn a new skill for seeking help. While 

Linda C. was helped by counseling strategies alone, others with “social phobia” also may need antidepressant medications in addition to counseling. 

136 Strategies for Working With Clients With Co-Occurring Disorders 
6 Traditional Settings 

and Models 

In This 

Chapter... 

Essential



Programming for



Clients With COD
 


Outpatient



Substance Abuse



Treatment
 


Programs for



Clients With COD
 


Residential



Substance Abuse



Treatment
 


Programs for



Clients With COD
 


Overview 

What happens to clients with co-occurring disorders (COD) who enter 

traditional substance abuse settings? How can programs provide the best 

possible services to these people? 

This chapter adopts a program perspective to examine both outpatient 

and residential settings, highlighting promising treatment models that 

have emerged both within the substance abuse field and elsewhere. It 

also discusses the various treatment approaches and models available to 

those working in substance abuse settings. 

The chapter opens with a review of the seven essential programming elements in COD programming for substance abuse treatment agencies that 

treat clients with COD: (1) screening, assessment, and referral; (2) mental and physical health consultation; (3) the use of a prescribing onsite 

psychiatrist; (4) medication and medication monitoring; (5) psychoeducational classes; (6) onsite double trouble groups; and (7) offsite dual 

recovery mutual self-help groups. These elements are applicable in both 

residential and outpatient programs. This section of the chapter also discusses general considerations in treatment of clients with COD. 

Essential background related to outpatient care for this population, 

including available data on its effectiveness, follows the discussion of 

essential programming. The chapter then turns to an overview of the 

critical factors in the successful design, implementation, evaluation, and 

maintenance of effective outpatient programs for clients with COD. Two 

examples of successful outpatient programs are highlighted: the 

Clackamas County Mental Health Center of Oregon City, Oregon, an 

outpatient substance abuse and mental health treatment center; and the 

Arapahoe House of Denver, Colorado, which is the State’s largest 

provider of substance abuse treatment services. These are intended to 

“prime the pump” for readers considering the addition of new program 

elements to serve clients with COD. The section closes with an exploration of two specialized outpatient models for clients with co-occurring 

137 
substance use and serious mental disorders, 

Assertive Community Treatment and Intensive 

Case Management. 

A discussion of residential substance abuse 

treatment programs for clients with COD completes the chapter. Like the discussion of outpatient care, this section describes the background and effectiveness of residential care for 

the COD population, the key issues that arise 

in program design and implementation, and the 

challenges of evaluating and sustaining residential programs. Modified therapeutic communities (MTCs)—forms of residential care particularly well suited to clients with COD—are 

described in detail. The chapter closes with a 

presentation of two other residential models: 

Gaudenzia, Inc., located in Norristown, 

Pennsylvania, which uses an MTC to provide 

care for its clients, the majority of whom have 

serious mental illness, and the Na’nizhoozi 

Center, Inc., located in the rural community of 

Gallup, New Mexico, a program that uses a 

range of culturally appropriate interventions to 

meet the needs of its predominantly AmericanIndian clients. 

Essential Programming 

for Clients With COD 

Individuals with COD are found in all addiction treatment settings, at every level of care. 

Although some of these individuals have serious 

mental illness and/or are unstable or disabled, 

many of them have relatively stable disorders 

of mild to moderate severity. As substance 

abuse treatment programs serve the increasing 

number of clients with COD, the essential program elements required to meet their needs 

must be defined clearly and set in place. 

Program components described in this section 

should be developed by any substance abuse 

treatment program seeking to provide integrated substance abuse and mental health services 

to clients with COD (that is, to attain the level 

of capacity associated with the “COD capable” 

classification defined in chapter 2). These elements have been culled from a variety of 

strategies, approaches, and models described 

in the TIP and from consensus panel discussion 

of current clinical programming. The panel 

believes these elements constitute the best practices currently available for designing COD 

programs in substance abuse treatment agencies. A detailed discussion of these elements 

appears in chapter 1. What follows are program considerations for implementing these 

essential components. 

Screening, Assessment, and 

Referral 

All substance abuse treatment programs should 

have in place appropriate procedures for 

screening, assessing, and referring clients with 

COD. It is the responsibility of each provider 

to be able to identify clients with both mental 

and substance use disorders and ensure that 

they have access to the care needed for each 

disorder. For a detailed discussion, see chapter 

4. If the screening and assessment process 

establishes a substance abuse or mental disorder beyond the capacity and resources of the 

agency, referral should be made to a suitable 

residential or mental health facility, or other 

community resource. Mechanisms for ongoing 

consultation and collaboration are needed to 

ensure that the referral is suitable to the treatment needs of persons with COD. 

Physical and Mental Health 

Consultation 

Any substance abuse treatment program that 

serves a significant number of clients with COD 

would do well to expand standard staffing to 

include mental health specialists and to incorporate consultation (for assessment, diagnosis, 

and medication) into treatment services. 

Adding a master’s level clinical specialist with 

strong diagnostic skills and expertise in working with clients with COD can strengthen an 

agency’s ability to provide services for these 

clients. These staff members could function as 

consultants to the rest of the team on matters 

related to mental disorders, in addition to 

138 Traditional Settings and Models 
being the liaison for a mental health consultant 

and provision of direct services. 

A psychiatrist provides services crucial to sustaining recovery and stable functioning for people with COD: assessment, diagnosis, periodic 

reassessment, medication, and rapid response 

to crises. (See the section below on the advantages of having a psychiatrist on staff as part of 

the treatment team.) If lack of funding prevents the substance abuse treatment agency 

from hiring a consultant psychiatrist, the agency could establish a collaborative relationship 

with a mental health agency to provide those 

services. A memorandum of agreement formalizes this arrangement and ensures the availability of a comprehensive service package for 

clients with COD. Such arrangements are used 

widely in the field, and examples of “best practices” are available (Ridgely et al. 1998; 

Treatment of Persons 2000). 

An onsite psychiatrist fosters 

the development

of substance

abuse treatment 

staff, enhancing 

their comfort 

and skill in 

assisting clients

with COD.

Prescribing Onsite Psychiatrist 

Adding an onsite psychiatrist in an addiction 

treatment setting to evaluate and prescribe 

medication for clients with COD has been 

shown to improve treatment retention and 

decrease substance use (Charney et al. 2001; 

Saxon and Calsyn 1995). The onsite psychiatrist brings diagnostic, medication, and psychiatric counseling services directly to the location 

clients are based for the major part of their 

treatment. This approach often is the most 

effective way to overcome barriers presented 

by offsite referral, including distance and travel limitations, the inconvenience of enrolling in 

another agency and of the separation of clinical 

services (more “red tape”), fears of being seen 

as “mentally ill” (if referred to a mental health 

agency), cost, and the difficulty of becoming 

comfortable with different staff. 

The consensus panel is aware that the cost of 

an onsite psychiatrist is a concern for many 

programs. Many agencies that use the onsite 

psychiatrist model find that they can afford to 

hire a psychiatrist part-time, even 4 to 16 

hours per week, and that a significant number 

of clients can be seen that way. A certain 

amount of that cost can be billed to Medicaid, 

Medicare, insurance agencies, or other funders. For larger agencies, the psychiatrist may 

be full time or share a full-time position with a 

nurse practitioner. The psychiatrist also can be 

employed concurrently by the local mental 

health program, an arrangement that helps to 

facilitate access to such other mental health 

services as intensive outpatient treatment, psychosocial programs, and even inpatient psychiatric care if needed. Studies describing this 

model more fully and including outcome data 

include Saxon and Calsyn (1995) and Charney 

and colleagues 

(2001). The 

approach also has 

been shown to be 

cost effective in a 

large health maintenance organization 

(Weisner et al. 

2001). 

Some substance 

abuse programs may 

be reluctant to hire 

a psychiatrist or to 

provide psychiatric 

services. This issue 

can be resolved 

through agencywide 

discussions of the 

types of clients with 

COD seen by the 

agencies, how their 

services are coordinated, and the barriers clients experience to receiving all 

the elements of COD 

treatment. In many cases, the largest and most 

obviously missing elements of good, integrated, 

onsite COD treatment are mental disorder 

diagnosis and treatment. It also should be 

noted that an onsite psychiatrist fosters the 

development of substance abuse treatment 

staff, enhancing their comfort and skill in 

assisting clients with COD. The psychiatrist 

may be able upgrade counselors’ skills through 

seminars on medication management and other 

Traditional Settings and Models 139 
pertinent topics. Also, the psychiatrist usually 

attends the weekly meeting of the clinical team, 

helping to develop effective treatment plans for 

active cases of clients with COD. For many psychiatrists, this arrangement also affords a welcome opportunity for further exposure to substance abuse treatment. 

Ideally, agencies should hire a psychiatrist 

with substance abuse treatment expertise to 

work onsite at the substance abuse treatment 

agency. Finding psychiatrists with this background may present a challenge. Psychiatrists 

certified by the American Society of 

Addiction Medicine (ASAM), the American 

Academy of Addiction Psychiatry, or the 

American Osteopathic Association (for osteopathic physicians) are good choices. They can 

provide leadership, advocacy, development, 

and consultation for substance abuse staff. 

Historically, however, substance abuse education in medical schools and residencies has 

received little attention, though promising 

efforts on multiple levels are working to 

ensure that all physicians receive at least a 

basic knowledge of substance use disorders. 

Thus, learning usually flows both ways, to the 

benefit of the client. When recruiting a psychiatrist, the substance abuse treatment program should discuss key issues around this bidirectional flow of clinical information and 

knowledge. In addition, a discussion of prescribing guidelines (such as those included in 

appendix F) is in order. 

The prescribing onsite psychiatrist model is a 

useful and recommended step that substance 

abuse treatment agencies can take to provide 

integrated COD treatment services. A detailed 

manual is needed to help agencies install this 

model and to guide the participating psychiatrists to provide the best services within the 

model. Further research is needed to document cost offsets for implementing the model 

and gauge its clinical effectiveness in a variety 

of substance abuse treatment settings. 

Medication and Medication 

Monitoring 

Many clients with COD require medication to 

control their psychiatric symptoms and to stabilize their psychiatric status. The importance 

of stabilizing the client with COD on psychiatric medication when indicated is now well 

established in the substance abuse treatment 

field. (See appendix F for a comprehensive 

description of the role of medication and the 

available medications.) One important role of 

the psychiatrist working in a substance abuse 

treatment setting is to provide psychiatric medication based on the assessment and diagnosis 

of the client, with subsequent regular contact 

and review of medication. These activities 

include careful monitoring and review of medication adherence. 

Psychoeducational Classes 

Substance abuse treatment programs can help 

their clients with COD by offering psychoeducational classes such as those described below. 

Mental and substance use 

disorders 

Psychoeducational classes on mental and substance use disorders are important elements in 

basic COD programs. These classes typically 

focus on the signs and symptoms of mental disorders, medication, and the effects of mental 

disorders on substance abuse problems. 

Psychoeducational classes of this kind increase 

client awareness of their specific problems and 

do so in a safe and positive context. Most 

important, however, is that education about 

mental disorders be open and generally available within substance abuse treatment programs. Information should be presented in a 

factual manner, similar to the presentation of 

information on sexually transmitted diseases 

(STDs). Some mental health clinics have prepared synopses of mental illnesses for clients in 

terms that are factual but unlikely to cause distress. A range of literature written for the 

layperson also is available through government 

140 Traditional Settings and Models 
agencies and advocacy groups (see appendix I). 

This material provides useful background 

information for the substance abuse treatment 

counselor as well as for the client. 

Relapse prevention 

Programs also can adopt strategies designed to 

help clients become aware of cues or “triggers” 

that make them more likely to abuse substances 

and help them develop alternative coping 

responses to those cues. Some providers suggest 

the use of “mood logs” that clients can use to 

increase their consciousness of the situational 

factors that underlie the urge to use or drink. 

These logs help answer the question, “When I 

have an urge to drink or use, what is happening?” Similarly, basic treatment agencies can 

offer clients training on recognizing cues for the 

return of psychiatric symptoms and for affect 

or emotion management, including how to 

identify, contain, and express feelings 

appropriately. 

Double Trouble Groups 

(Onsite) 

Onsite groups such as “Double Trouble” provide a forum for discussion of the interrelated 

problems of mental disorders and substance 

abuse, helping participants to identify triggers 

for relapse. Clients describe their 

psychiatric symptoms (e.g., hearing voices) and their urges to use 

drugs. They are encouraged to 

discuss, rather than to act on, 

these impulses. Double Trouble 

groups also can be used to monitor medication adherence, psychiatric symptoms, substance use, 

and adherence to scheduled activities. Double Trouble provides a 

constant framework for assessment, analysis, and planning. 

Through participation, the individual with COD develops perspective on the interrelated 

nature of mental disorders and 

substance abuse and becomes better able to view his or her behavior within this 

framework. 

Dual Recovery Mutual SelfHelp Groups (Offsite) 

Fortunately, a variety of dual recovery mutual 

self-help groups exist in many communities. 

Substance abuse treatment programs can refer 

clients to dual recovery mutual self-help 

groups, which are tailored to the special needs 

of a variety of people with COD. These groups 

provide a safe forum for discussion about medication, mental health, and substance abuse 

issues in an understanding, supportive environment wherein coping skills can be shared. 

Chapter 7 contains a comprehensive description of this approach and a listing of organizations that provide such services. See also 

appendix J, which provides a list of such programs, their characteristics, and contacts. 

General Considerations for 

Treatment 

In addition to these seven essential elements of 

COD programming, all treatment providers 

would do well to develop specific approaches to 

working with COD clients in groups and find 

meaningful ways of including them in program 

design. Since families can have a powerful 

Advice to Administrators: 

Recommendations for Providing 

Essential Services for People With COD 

Develop a COD Program with the following components: 

1. Screening, assessment, and referral for persons with 

COD 

2. Physical and mental health consultation 

3. Prescribing onsite psychiatrist 

4. Medication and medication monitoring 

5. Psychoeducational classes 

6. Double trouble groups (onsite) 

7. Dual recovery self-help groups (offsite) 

Traditional Settings and Models 141 
influence on a client’s recovery, it is especially 

important to reach out to the families of persons with COD and help them understand more 

about COD and how they can best support the 

client and help the person recover. 

Working in groups 

Group therapy in substance abuse treatment 

settings is regarded generally as a key feature 

of substance abuse treatment. However, group 

therapy should be augmented by individual 

counseling since 

individual contact is 

important in helping 

the client with COD 

make maximum use

of group interventions.

Group therapy 

should be modified 

for clients with 

COD. Generally, it 

is best to reduce the 

emotional intensity

of interpersonal 

interaction in COD

group sessions; 

issues that are nonprovocative to 

clients without COD 

may lead to reactions in clients with 

COD. Moreover, 

because many 

clients with COD often have difficulty staying 

focused, their treatment groups usually need 

stronger direction from staff than those for 

clients who do not have COD. Typically, some 

persons with COD have trouble sitting still, 

while others may have trouble getting moving 

at all (for instance, some people with depression); therefore, the duration of a group (and 

other activities) should be shortened to less 

than an hour, with the typical group or activity 

running for no more than 40 minutes. Because 

of the need for stability, the groups should run 

regularly and without cancellation. 

It is not uncommon for groups 

tailored to individuals with 

COD to consist 

of between two 

and four individuals in the 

early stages. 

Because many clients with COD have difficulty in social settings, group sizes may need to 

be smaller than is typical. There is benefit 

even to allowing a few individuals to be considered a group, so long as sessions are 

group-oriented and used as a means to introduce the client to a larger group setting. It is 

not uncommon for groups tailored to individuals with COD to consist of between two and 

four individuals in the early stages. Co-leaders are especially important in these groups, 

as one leader may need to leave the group 

with one member, while the group continues 

with the co-leader. With appropriate staff 

guidance, peers who have completed the program or advanced to its latter stages can 

sometimes be used as group cofacilitators. 

Considerable tolerance is needed for varied 

(and variable) levels of participation depending on the client’s level of functioning, stability of symptoms, response to medication, and 

mental status. Many clients with serious mental illness (e.g., those with a diagnosis of 

schizophrenia, schizoid and paranoid personality) may not fit well in groups and must be 

incorporated gradually at their own pace and 

to the degree they are able to participate. 

Even minimal or inappropriate participation 

can be viewed as positive in a given case or 

circumstance. Verbal communication from 

group leaders should be brief, simple, concrete, and repetitive. This is especially important to reach clients with cognitive and functional impairments. Affirmation of accomplishments should be emphasized over disapproval or sanctions. Negative behavior should 

be amended rapidly with a positive learning 

experience designed to teach the client a correct response to a situation. In general, group 

leaders will need to be sensitive and responsive to needs of the client with COD and the 

addition of special training can enhance his 

or her competency. TIP 41, Substance Abuse 

Treatment: Group Therapy (Center for 

Substance Abuse Treatment [CSAT] 2005) 

contains more information on the techniques 

and types of groups used in substance abuse 

treatment. 

142 Traditional Settings and Models 
Involving clients in treatment 

and program design 

Because clients can provide important guidance 

relative to their treatment and valuable feedback on program design and effectiveness, they 

should be involved in program discussions. 

Some guidelines for involving client/consumers 

include: 

•Form a Consumer Advisory Group. 

•Include both current clients from the program and past clients. 

•Elect a client representative to discuss client 

concerns with staff. 

•Provide a staff liaison to help coordinate 

client meetings and to provide a continuing 

link to staff. 

•Hold regular meetings and phone conferences. 

•Provide incentives to clients for participation. 

•Solicit input on a variety of matters and in an 

ongoing way. 

•Involve clients in meaningful projects. 

•When client input is solicited and received, 

consider it respectfully, respond appropriately, and give the client feedback on your 

response. 

Family education 

It is important that family members and significant others who are close to the client receive 

information on mental disorders and substance 

abuse, as well as on how the disorders interact 

with one another. Particularly in cultures that 

value interdependence and are communityand/or family-oriented, a family and community education and support group can be helpful. 

In an effort to build or maintain support for 

the client and his treatment, family members 

and significant others need to understand the 

implications of having COD and the treatment 

options available to the client. Programs must 

provide this instruction in an interactive style 

that allows questions, not in a lecture mode. 

The essentials of this information include: 

• The name of the disorder 

• Its symptoms 

• Its prevalence 

• Its cause 

• How it interacts with substance abuse—that 

is, the implications of having both disorders 

• Treatment options and considerations in 

choosing the best treatment 

• The likely course of the illness 

• What to expect 

• Programs, resources, and individuals who 

can be helpful 

Outpatient Substance 

Abuse Treatment 

Programs for Clients 

With COD 

Background and Effectiveness 

Treatment for substance abuse occurs most 

frequently in outpatient settings—a term that 

subsumes a wide variety of disparate programs (Simpson et al. 1997b). Some offer several hours of treatment each week, which can 

include mental health and other support services as well as individual and group counseling for substance abuse; others provide minimal services, such as only one or two brief 

sessions to give clients information and refer 

them elsewhere (Etheridge et al. 1997). Some 

agencies offer outpatient programs that provide services several hours per day and several days per week, thus meeting ASAM’s criteria for Intensive Outpatient Programs. 

Typically, treatment includes individual and 

group counseling, with referrals to appropriate community services. Until recently, there 

were few specialized approaches for people 

with COD in outpatient substance abuse 

treatment settings. One of many small exceptions was a methadone maintenance program 

that also made psychiatrists and mental 

health services available to its clients (Woody 

et al. 1983). 

Traditional Settings and Models 143 
Deinstitutionalization and other factors are 

increasing the prevalence of persons with 

COD in outpatient programs. Many of these 

individuals have multiple health and social 

problems that complicate their treatment. 

Evidence from prior studies indicates that a 

mental disorder often makes effective treatment for substance use more difficult (Mueser 

et al. 2000; National Association of State 

Mental Health Program Directors and 

National Association of State Alcohol and 

Drug Abuse Directors 1999). Because outpatient treatment programs are available widely 

and serve the greatest number of clients 

(Committee on Opportunities in Drug Abuse 

Research 1996; Lamb et al. 1998), using current best practices from the substance abuse 

treatment and mental health services fields is 

vital. Doing so enables these programs to use 

the best available treatment models to reach 

the greatest possible number of persons with 

COD. 

Prevalence 

COD is clearly a defining characteristic commonly found in clients who enter substance 

abuse treatment. A Drug Abuse Treatment 

Outcome Study (DATOS) of 99 treatment programs in 11 U.S. metropolitan areas between 

1991 and 1993 found the following distribution of co-occurring mental disorders: 39.3 

percent met DSM-III-R (Diagnostic and 

Statistical Manual of Mental Disorders, 3rd 

edition, revised [American Psychiatric 

Association 1987]) diagnostic criteria for antisocial personality disorder, 11.7 percent met 

criteria for a major depressive episode, and 

about 3.7 percent met criteria for a general 

anxiety disorder (Flynn et al. 1996) (see also 

Figure 1-2 in chapter 1). DATOS and other 

data indicate that substance abuse programs 

can expect a substantial proportion of the 

clientele to have COD. 

Empirical evidence of effectiveness 

Evidence suggests that outpatient treatment 

can lead to positive outcomes for certain 

clients with COD, even when treatment is not 

tailored specifically to their needs. Outpatient 

substance abuse treatment programs can be 

effective settings for treating substance abuse 

in clients with less serious mental disorders. 

This conclusion is supported by evidence 

from the most current and comprehensive 

database on substance abuse treatment, the 

DATOS dataset (Flynn et al. 1997). 

Clients who were in outpatient treatment, 

including individual and group counseling 

and mutual self-help groups, showed reductions in drug use after treatment. Clients with 

3 months or more of outpatient treatment 

reported even lower rates of drug use compared to their rate of use prior to treatment 

(Hubbard et al. 1997; Simpson et al. 1997a). 

These data show that substance abuse treatment outpatient programs can help clients, 

many with COD, who remain in treatment at 

least 3 months. However, modifications 

designed to address issues faced even by those 

with less serious mental disorders can 

enhance treatment effectiveness and in some 

instances are essential. 

Designing Outpatient 

Programs for Clients With 

COD 

The population of persons with COD is heterogeneous in terms of motivation for treatment, nature and severity of substance use 

disorder (e.g., drug of choice, abuse versus 

dependence, polysubstance abuse), and 

nature and severity of mental disorder. For 

the most part, however, clients with COD in 

outpatient treatment have less serious and 

more stabilized mental and substance abuse 

problems compared to those in residential 

treatment (Simpson et al. 1999). 

144 Traditional Settings and Models 
Outpatient treatment can be the primary 

treatment or can provide continuing care for 

clients subsequent to residential treatment, 

which implies a degree of flexibility in the 

activities/interventions and the intensity of 

the treatment approaches. However, reports 

from clinical administrators indicate that an 

increasing number of clients with serious 

mental illness (SMI) and substance abuse 

problems are entering the outpatient substance abuse treatment system. Treatment 

failures occur with both people with SMI and 

those with less serious mental illness for several reasons, but among the most important 

are that programs lack the resources to provide the time for mental health services and 

medications that, in all likelihood, significantly would improve recovery rates and recovery 

time. 

If lack of funding prevents the full integration 

of mental health assessment and medication 

services within a substance abuse treatment 

agency that provides outpatient services, 

establishing a collaborative relationship with 

a mental health agency (through the mechanism of a memorandum of agreement) would 

ensure that the services for the clients with 

COD are adequate and comprehensive. In 

addition, modifications are needed both to 

the design of treatment interventions and to 

the training of staff to ensure implementation 

of interventions appropriate to the needs of 

the client with COD. 

To meet the needs of specific populations 

among persons with COD, the consensus 

panel encourages outpatient treatment programs to develop special services for populations that are represented in significant numbers in their programs. Examples include 

women, women with dependent children, 

homeless individuals and families, racial and 

ethnic minorities, and those with health problems such as HIV/AIDS. Several substance 

abuse treatment agencies have already developed programs for specialized subpopulations. Two such programs—the Clackamas 

County Mental Health Center (women, criminal justice, young adults) and Arapahoe 

House (women with children, homeless persons)—are described later in this chapter. 

Since the types of co-occurring disorder will 

vary according to the subpopulation targeted, 

each of these programs must deal with COD 

in a somewhat different manner, often by 

adding other treatment components for COD 

to existing program models. 

A centralized

intake team is a 

useful approach 

to screening and

assessment, providing a common point of

entry for many 

clients entering 

treatment. 

Screening and assessment 

As chapter 4 provides a full discussion of 

assessment, this 

section will address 

only those screening and assessment 

issues of concern in 

outpatient settings 

or that deserve 

reiteration in this 

specific context. 

Screening and 

assessment are used 

to make two essential decisions: 

1. Is the individual 

stable enough to 

remain in an 

outpatient setting, or is more 

intense care indicated, warranting rapid referral to an appropriate alternative treatment? 

2. What services 

will the client need? 

To answer either question, staff must first 

determine the scope of the client’s problems, 

including his physical and mental status, living 

situation, and the support he has available to 

face these problems. Whereas screening 

requires basic counseling skills, the consensus 

panel recommends that only specially trained 

or highly capable staff should perform assessTraditional Settings and Models 145 
ments—not, as is too often the case, less experienced personnel. 

A thorough assessment should establish the 

client’s mental and physical status. The process should determine any preexisting medical 

conditions or complications, substance use 

history, level of cognitive functioning, prescription drug needs, current mental status, 

and mental health history. 

Centralized intake 

A centralized intake team is a useful 

approach to screening and assessment, providing a common point of entry for many 

clients entering treatment. When applied in 

an agency with multiple programs, centralized intake reduces duplication of referral 

materials as well as assessment services. At 

Arapahoe House (a model described later in 

this chapter), the information and access 

team manages hundreds of telephone calls 

weekly, conducts screenings, and sets 

appointments for admission to any of the programs within the agency, with the exception of 

three detoxification programs. Where centralized intake serves a multi-modality treatment 

organization or a community with multiple 

settings (the latter being especially difficult), 

the intake process can be used to refer clients 

to the treatment modality most appropriate to 

their needs (e.g., residential or outpatient), so 

long as careful attention is paid to the accurate coordination of intake information. 

Reassessment 

Once admitted to treatment, clients need regular reassessment as reductions in acute symptoms of mental distress and substance abuse 

may precipitate other changes. Periodic assessment will provide measures of client change 

and enable the provider to adjust service plans 

as the client progresses through treatment. 

Referral and placement 

Careful assessment will help to identify those 

clients who require more secure inpatient 

treatment settings (e.g., clients who are 

actively suicidal or homicidal), as well as 

those who require 24-hour medical monitoring, those who need detoxification, and those 

with serious substance use disorders who may 

require a period of abstinence or reduced use 

before they can engage actively in all treatment components. TIP 29, Substance Use 

Disorder Treatment for People With Physical 

and Cognitive Disabilities (CSAT 1998e), contains information on assessing physical and 

cognitive functioning that is relevant for all 

populations. 

It is important to view the client’s placement 

in outpatient care in the context of continuity 

of care and the network of available 

providers and programs. Outpatient treatment programs may serve a variety of functions, including outreach/engagement, primary treatment, and continuing care. Ideally, a 

full range of outpatient substance abuse treatment programs would include interventions 

for unmotivated, disaffiliated clients with 

COD, as well as for those seeking abstinencebased primary treatments and those requiring 

continuity of supports to sustain recovery. 

Likewise, ideal outpatient programs will facilitate access to services through rapid 

response to all agency and self-referral contacts, imposing few exclusionary criteria, and 

using some client/treatment matching criteria 

to ensure that all referrals can be engaged in 

some level of treatment. In those instances 

where funding for treatment is controlled by 

managed care, additional levels of control 

over admission may be imposed on the treatment agency. The consensus panel has mentioned that treatment providers should be 

careful not to place clients in a higher level of 

care (i.e., more intense) than is necessary. A 

client who might remain engaged in a less 

intense treatment environment may drop out 

in response to the demands of a more intense 

treatment program. 

146 Traditional Settings and Models 
Improving Adherence of Clients With COD in 

Outpatient Settings 

Source: Adapted from Daley and Zuckoff 1998. 

•Use telephone or mail reminders. 

•Provide reinforcement for attendance (e.g., snacks, lunch, or reimbursement for transportation). 

•Increase the frequency and intensity of the outpatient services offered. 

•Develop closer collaboration between referring staff and the outpatient program’s staff. 

•Reduce waiting times for outpatient appointments. 

•Have outpatient programs designed particularly for clients with COD. 

•Provide clients with case managers who engage in outreach and provide home visits. 

•Coordinate treatment and monitoring with other systems of care providing services to the same client. 

Engagement 

Clients with COD, especially those opposed to 

traditional treatment approaches and those 

who do not accept that they have COD, have 

particular difficulty committing to and maintaining treatment. By providing continuous 

outreach, engagement, direct assistance with 

immediate life problems (e.g., housing), advocacy, and close monitoring of individual 

needs, the Assertive Community Treatment 

(ACT) and Intensive Case Management (ICM) 

models (described below) provide techniques 

that enable clients to access services and foster the development of treatment relationships. In the absence of such supports, those 

individuals with COD who are not yet ready 

for abstinence-oriented treatment may not 

adhere to the treatment plan and may be at 

high risk for dropout (Drake and Mueser 

2000). 

Because clients with COD often have poor 

treatment engagement, it is particularly 

important that every effort be made to 

employ methods with the best prospects for 

increasing engagement. Daley and Zuckoff 

(1998) note a number of useful strategies for 

improving engagement and adherence with 

this population. 

Discharge planning 

Discharge planning is important to maintain 

gains achieved through outpatient care. Clients 

with COD leaving an outpatient substance 

abuse treatment program have a number of 

continuing care options. These options include 

mutual self-help groups, relapse prevention 

groups, continued individual counseling, mental health services (especially important for 

clients who will continue to require medication), as well as intensive case management 

monitoring and supports. A carefully developed discharge plan, produced in collaboration 

with the client, will identify and match client 

needs with community resources, providing the 

supports needed to sustain the progress 

achieved in outpatient treatment. 

Clients with COD often need a range of services besides substance abuse treatment and 

mental health services. Generally, prominent 

needs include housing and case management 

services to establish access to community 

health and social services. In fact, these two 

services should not be considered “ancillary,” 

but key ingredients for clients’ successful 

recovery. Without a place to live and some 

degree of economic stability, clients with COD 

are likely to return to substance abuse or 

experience a return of symptoms of mental 

disorder. Every substance abuse treatment 

Traditional Settings and Models 147 
provider should have, and many do have, the 

strongest possible linkages with community 

resources that can help address these and 

other client needs. Clients with COD often 

will require a wide variety of services that 

cannot be provided by a single program. 

It is imperative that discharge planning for 

the client with COD ensures continuity of psychiatric assessment 

and medication 

management, without which client 

stability and recovery will be severely 

compromised. 

Relapse prevention 

interventions after 

outpatient treatment need to be 

modified so that

the client can recognize symptoms of

psychiatric or substance abuse 

relapse on her own 

and can call on a 

learned repertoire 

of symptom management techniques 

(e.g., self-monitoring, reporting to a

“buddy,” and 

group monitoring).

This also includes 

the ability to access 

assessment services 

rapidly, since the return of psychiatric symptoms can often trigger substance abuse 

relapse. 

Developing positive peer networks is another 

important facet of discharge planning for continuing care. The provider seeks to develop a 

support network for the client that involves 

family, community, recovery groups, friends, 

and significant others. Where a client’s family 

of origin is not healthy and supportive, other 

networks can be accessed or developed that 

will support him. Programs also should 

encourage client participation in mutual selfhelp groups, particularly those that focus on 

COD (e.g., dual recovery mutual self-help 

programs). These groups can provide a continuing supportive network for the client, who 

usually can continue to participate in such 

programs even if he moves to a different community. Therefore, these groups are an 

important method of providing continuity of 

care. 

The consensus panel also recommends that 

programs working with clients with COD try 

to involve advocacy groups in program activities. These groups can help clients become 

advocates themselves, furthering the 

development and responsiveness of the treatment program while enhancing clients’ sense 

of self-esteem and providing a source of 

affiliation. 

The provider 

seeks to develop 

a support network for the 

client that 

involves family, 

community, 

recovery 

groups, friends,		

and significant 

others. 

Continuing care 

Continuing care and relapse prevention are 

especially important with this population, 

since people with COD are experiencing two 

long-term conditions (i.e., mental disorder 

often is a cyclical, recurring illness; substance 

abuse is likewise a condition subject to 

relapse). Clients with COD often require longterm continuity of care that supports their 

progress, monitors their condition, and can 

respond to a return to substance use or a 

return of symptoms of mental disorder. 

Continuing care is both a process of posttreatment monitoring and a form of treatment 

itself. (In the present context, the term “continuing care” is used to describe the treatment options available to a client after 

leaving one program for another, less intense, 

program.) 

The relative seriousness of a client’s mental 

and substance use disorders may be very different at the time she leaves a primary treatment provider; thus, different levels of intervention will be appropriate. After leaving an 

outpatient program, some clients with COD 

148 Traditional Settings and Models 
may need to continue intensive mental health 

care but can manage their substance abuse 

treatment by participation in mutual self-help 

groups. Others may need minimal mental 

health care but require some form of continued formal substance abuse treatment. For 

people with SMI, continued treatment often is 

warranted; a treatment program can provide 

these clients with structure and varied services not usually available from mutual selfhelp groups. 

Upon leaving a program, clients with COD 

always should be encouraged to return if they 

need assistance with either disorder. Because 

the status of these individuals can be fragile, 

they need to be able to receive help or a 

referral quickly in times of crisis. Regular 

informal check-ins with clients also can help 

alleviate potential problems before they 

become serious enough to threaten recovery. 

A good continuing care plan will include steps 

for when and how to reconnect with services. 

The plan and provision of these services also 

makes readmission easier for clients with 

COD who need to come back. The client with 

COD should maintain contact postdischarge 

(even if only by telephone or informal gatherings). Increasingly, substance abuse programs 

are undertaking follow-up contact and periodic groups to monitor client progress and 

assess the need for further service. 

Implementing Outpatient 

Programs 

The challenge of implementing outpatient 

programs for COD is to incorporate specific 

interventions for a particular subgroup of 

outpatient clients into the structure of generic 

services available for a typically heterogeneous population. Often this is best accomplished by establishing a separate track for 

COD consisting of the services described in 

the section on essential programming above. 

Accomplishing this implies organizational 

change as substance abuse and mental health 

service agencies modify their mission to 

address the special needs of persons with 

COD. Note that the section on residential 

treatment contains some additional principles 

of implementation that are equally applicable 

to outpatient programs. 

Staffing 

To accommodate clients with COD, standard 

outpatient drug treatment staffing should 

include both mental health specialists and 

psychiatric consultation and access to onsite 

or offsite psychopharmacologic consultation. 

All treatment staff should have sufficient 

understanding of the substance use and mental disorders to implement the essential elements described above. Ideally, this staffing 

pattern would include mental health clinicians with master’s level education, strong 

diagnostic skills, and substantial experience 

with clients with COD. These clinicians could 

provide a link to psychiatric services as well 

as to consultation on other clinical activities 

within the program. It is important that the 

staff function as an integrated team. Staff 

cooperation can often be fostered by crosstraining, clinical team meetings and, most 

importantly, a treatment culture that stresses 

teamwork and collaboration. 

Training 

An integrated model of treatment for clients 

with COD requires that each member of the 

treatment team has substantial competency in 

both fields. Both mental health and substance 

abuse treatment staff require training, crosstraining, and on-the-job training to meet adequately the needs of clients with COD. Within 

substance abuse treatment settings, this means 

training in these areas: 

• Recognizing and understanding the symptoms 

of the various mental disorders 

• Understanding the relationships between different mental symptoms, drugs of choice, and 

treatment history 

• Individualizing and modifying approaches to 

meet the needs of specific clients and achieve 

treatment goals 

Traditional Settings and Models 149 
•Accessing services from multiple systems and 

negotiating integrated treatment plans 

The addition of mental health staff into a substance abuse treatment setting also raises the 

need for training. Training should address 

•Differing perspectives regarding the characteristics of the person with COD 

•The nature of addiction 

•The nature of mental disability 

•The conduct of treatment and staff roles in 

the treatment process 

•The interactive effects of both conditions on 

the person and his or her outcomes 

•Staff burnout 

Staff trained exclusively either in mental health 

services or in substance abuse treatment models often have difficulty accepting the other’s 

view of the person, the problem, and the 

approach to treatment. Cross-training and 

open discussion of differing viewpoints and 

challenging issues can help staff to reach a common perspective and approach for the treatment of clients with COD within each agency or 

program setting. Chapter 3 provides a more 

complete discussion of staff training, while 

appendix I identifies a number of training 

resources. 

Evaluating Outpatient 

Programs 

Five elements are needed to design an evaluation process for an outpatient program that can 

provide useful feedback to program staff and 

administrators on the effectiveness or outcome 

of treatment for persons with COD. These 

important data can be used to improve programs. 

1.		Define the operational goals of the program in terms of the client behaviors for 

which change is sought. Programs may 

define their goals for client change narrowly in terms of reductions in alcohol and 

drug use and crime only or more broadly, 

to include reductions in psychological 

symptoms, homelessness, unemployment, 

and so on. 

2. 	Decide who the study clients will be and 

devise a plan for selecting or sampling 

those clients. Depending on the rate of 

client entry into a program and the number of clients sought for the outcome study 

(typically at least 35), a program may 

select every client presenting to treatment 

over the course of a designated time period 

or may sample systematically (e.g., taking 

every third client) or randomly (e.g., using 

a coin toss). It is important to use a system 

that avoids bias (i.e., avoids the selection 

of clients who, for one reason or another, 

are believed to be more likely to respond 

particularly well or particularly poorly to 

the treatment program). 

3. 	Locate and/or develop instruments that 

can be used to assess client functioning in 

the areas of concern for outcome. Include 

areas about which the program staff feels 

information is needed (e.g., demographic 

characteristics and background variables 

such as source of referral, drug use and 

criminal justice histories, education or 

employment histories, prior drug treatment, social support, physical and mental 

health histories, etc.). For studies generally, and for in-treatment studies in particular, it is also important to gather information about client retention. Indeed, a number of studies now suggest that length of 

retention is a useful proxy measure for 

understanding posttreatment outcomes, 

and that retention to 3 months in outpatient programs is critical for clients to 

achieve meaningful behavior change. 

4. 	Develop a plan for data collection. 

Information on client functioning can be 

gathered using selected instruments at the 

time of entry into treatment (baseline) and 

at intervals of 1 or more months from time 

of entry while the individual is in treatment. Data gathered may be restricted to 

self-report or may include biological markers such as urinalysis and/or data gathered 

from others knowledgeable about the 

client’s functioning (e.g., family or school 

150 Traditional Settings and Models 
personnel). Outcome studies frequently 

involve continuing assessment after the 

client leaves treatment, and again at designated intervals; typically, assessments at 

6- to 12-month intervals. 

5. Develop a plan for data analysis and 

reporting. Data analysis may be comparatively simple, describing client functioning 

at baseline in the areas of concern (e.g., 

drug use) and client functioning in those 

same areas at times of assessment or follow-up; alternatively, it may be complex, 

comparing client functioning in the areas 

of concern at multiple points in time and 

controlling for variables that might affect 

that functioning (e.g., prior treatment history). The findings obtained through data 

analysis are communicated through written and oral reporting to interested parties, particularly program staff who can 

use this information on program effectiveness to its greatest advantage (i.e., to 

improve the program’s capacity to facilitate client change). Both the National 

Institute on Drug Abuse (NIDA) and CSAT 

have developed manuals for outcome studies designed to be conducted by treatment 

program staff. NIDA’s document (1993) is 

titled How Good Is Your Drug Abuse 

Treatment Program? A Guide to 

Evaluation. CSAT’s document (1997b) is 

titled Demystifying Evaluation: A Manual 

for Evaluating Your Substance Abuse 

Treatment Program. 

Sustaining Outpatient 

Programs 

Funding resources for substance abuse treatment remain significantly lower per client than 

those available for mental health services. 

Models demonstrating positive results originating in the mental health field often are too 

expensive to be implemented fully in more fiscally limited substance abuse treatment settings. The consensus panel recommends developing funding for the essential programming 

described in this chapter and, where possible, 

for adapting the successful models for the treatment of mental disorders in outpatient settings 

described below. 

Since the majority of substance

abuse treatment

agencies treat 


clients with 


COD, an obvi­


ous solution to 

funding shortfalls is to access

funding streams 

that support 

mental health 

services. 

Financing integrated 

treatment 

As noted earlier, systemic difficulties related to 

the organization and financing of integrated 

treatment models, including funding for 

enhanced mental health services, have delayed 

implementation of 

integrated treatment 

models in many outpatient substance 

abuse treatment settings. Resources for 

funding extended 

continuity of treat­


ment, which are 


available generally 

in mental health set­


tings, are not usually 

provided in sub­


stance abuse treatment systems. Since 


the majority of sub­


stance abuse treatment agencies treat 

clients with COD, an 

obvious solution to 

funding shortfalls is 

to access funding 

streams that support 

mental health services. Such funding 

may be based on 

demonstrating the 

nature, severity, and 

extent of co-occurring mental disorders among their 

clients, with documentation of the full 

range of diagnosed disabilities of clients with 

COD. This information also helps programs to 

modify their programs to address current client 

needs, and to educate and promote an appreciation for the documented efficacy of integrated 

treatment for those with COD (Drake et al. 

Traditional Settings and Models 151 
1998b). Chapter 3 presents additional information on overcoming barriers and for accessing 

funding for COD in substance abuse treatment 

settings. 

Planning for organizational 

change 

Substance abuse treatment agencies should 

plan for any organizational changes needed to 

introduce new or altered approaches into 

program settings (e.g., adding and integrating 

mental health staff into the substance abuse 

setting). Agencies should be aware, however, 

that changing the processes and approaches 

in an organization is challenging. Strategies 

should be grounded in sound organizational 

change principles and may be effective in 

helping all parties understand, accept, and 

adjust to the changes. A recommended 

sourcebook administrators might find useful 

is The Change Book: A Blueprint for 

Technology Transfer (Addiction Technology 

Transfer Center National Office 2000). 

Examples of Outpatient 

Programs 

A CSAT initiative, titled Grants for 

Evaluation of Outpatient Treatment Models 

for Persons With Co-Occurring Substance 

Abuse and Mental Health Disorders 

(Substance Abuse and Mental Health Services 

Administration [SAMHSA] 2000) promotes 

the development and evaluation of new models for the treatment of COD in outpatient 

substance abuse treatment settings. A variety 

of models for treatment of clients with COD 

in outpatient substance abuse treatment settings are now emerging, some of which are 

outlined in appendix E. 

Recognizing that providers must address 

these issues within the constraints of particular systems that differ significantly from each 

other, two providers have been chosen—the 

Clackamas County Mental Health Center, 

Oregon, and Arapahoe House, Colorado—to 

illustrate different approaches to providing 

outpatient care for clients with COD. 

Assertive Community 

Treatment and Intensive Case 

Management: Specialized 

Outpatient Treatment Models 

for Clients With COD 

This section focuses on two existing outpatient 

models, ACT and ICM (both from the mental 

health field) and the challenges of employing 

them in the substance abuse field. The rationale for selecting these specialized models is 

that the framework, model, and methods of 

each are articulated clearly, both have been 

disseminated widely and applied, and each 

has support from a body of empirical evidence (though the empirical support for ICM 

is relatively modest compared to ACT). 

Because service systems are layered and difficult to negotiate, and because people with COD 

need a wide range of services but often lack the 

knowledge and ability to access them, the utility of case management is recognized widely for 

this population. Although ACT and ICM can be 

thought of as similar in several features (e.g., 

both emphasize case management, skills training, and individual counseling), they function 

differently from each other with regard to 

goals, operational characteristics, and the 

nature and extent of the activities and interventions they provide. Therefore, each is 

described separately below. 

Assertive Community 

Treatment 

Developed in the 1970s by Stein and Test (Stein 

and Test 1980; Test 1992) in Madison, 

Wisconsin, for clients with SMI, the ACT 

model was designed as an intensive, long-term 

service for those who were reluctant to engage 

in traditional treatment approaches and who 

required significant outreach and engagement 

activities. ACT has evolved and been modified 

to address the needs of individuals with serious 

mental disorders and co-occurring substance 

use disorders (Drake et al. 1998a; Stein and 

Santos 1998). 

152 Traditional Settings and Models 
The Clackamas County Mental Health Center, Oregon 

Overview 

Clackamas County is a geographically large county in northwest Oregon that is about the size of the State of 

Delaware and encompasses urban, suburban, and rural areas. Oregon City, the county seat, is home to 

15,000 people. The County provides outpatient substance abuse and mental health treatment services at four 

major clinics throughout the county. Its substance abuse treatment program has made a concerted and sustained effort to develop working agreements with major sources of referral, reflecting client needs in the community (e.g., corrections, child protective services, adult and family services, and a local community college). 

In addition, the program continues to consult with other service providers to build further linkages. 

All staff members who provide initial assessment and treatment have at least master’s level training and substance abuse certification (or its equivalent), which has facilitated the awareness of potential co-occurring 

interactions beginning at intake. It is recognized that this level of staffing is unusual within substance abuse 

treatment programs. 

Clients Served 

The county provides treatment for clients with substance abuse and COD. The Clackamas County Mental 

Health Center has a number of programs that target specific populations, including a women’s program; a 

program for clients involved in the criminal justice system who are on electronic surveillance or who were 

referred by juvenile and adult Drug Courts; clients with serious and persistent mental illness; and through 

the Passport Program, young adult men and women ages 17 to 23 who have co-occurring substance use disorders and significant mental disorders. 

Services 

Each clinic offers both Level 1 and 2 services (as defined by ASAM) (2001) and has working agreements with 

residential treatment programs for those who need that level of care. Outpatient services include treatment 

for individuals, families, and groups; case management; and consultation. More specialized treatment has 

been developed for some subpopulations within the program (e.g., clients with serious and persistent mental 

illness, clients on electronic surveillance, women). 

Program model 

ACT programs typically employ intensive outreach activities, active and continued engagement with clients, and a high intensity of services. ACT emphasizes shared decisionmaking 

with the client as essential to the client’s 

engagement process (Mueser et al. 1998). 

Multidisciplinary teams including specialists in 

key areas of treatment provide a range of services to clients. Members typically include mental health and substance abuse treatment counselors, case managers, nursing staff, and psychiatric consultants. The ACT team provides 

the client with practical assistance in life management as well as direct treatment, often within the client’s home environment, and remains 

responsible and available 24 hours a day (Test 

1992). The team has the capacity to intensify 

services as needed and may make several visits 

each week (or even per day) to a client. 

Caseloads are kept smaller than other community-based treatment models to accommodate 

the intensity of service provision (a 1:12 staffto-client ratio is typical). 

ACT treatment activities and 

interventions 

Examples of ACT interventions include 

•Outreach/engagement. To involve and sustain clients in treatment, counselors and 

administrators must develop multiple means 

of attracting, engaging, and re-engaging 

clients. Often the expectations placed on 

Traditional Settings and Models 153 
Arapahoe House, Colorado 

Overview 

Arapahoe House, a nonprofit corporation located near Denver, Colorado, is the State’s largest provider of 

substance abuse treatment services. In addition, Arapahoe House is a licensed mental health clinic and strives 

to provide fully integrated services for clients with COD in all of its treatment programs. Because all Arapahoe 

House programs are designed to provide integrated treatment for clients with COD, the agency employs several 

psychiatrists on contract in both the residential and outpatient settings. 

Clients Served 

The Arapahoe House Adult Outpatient Programs admit clients with substance use disorders who do not 

require 24-hour medical monitoring or detoxification and do not have symptoms of mental illness that place 

them at high risk of harming themselves or others. Adult clients who do not meet these criteria are referred to 

Arapahoe House’s detoxification services or its inpatient treatment program where they can receive comprehensive assessment and stabilization. Arapahoe House also has a number of programs for specific populations. 

There is a residential treatment program for women with dependent children and specialized services for 

homeless persons. 

Services 

Arapahoe House provides a full continuum of treatment services, including residential and outpatient treatment for adults and adolescents of multiple levels of intensity; case management services for specific target 

populations; nonmedical detoxification services; housing and vocational services; and, for adolescents, schoolbased counseling. The organization offers outpatient services at six locations in the metropolitan Denver area. 

These outpatient programs provide individual and group therapy, education, family counseling, sobriety monitoring, and mental health evaluation. 

Arapahoe House also provides a wide array of services devoted to the needs of homeless persons, including 

intensive case management services and a housing program. Specific services for persons with COD include the 

20-bed adult short-term intensive residential treatment program, the six adult outpatient clinics, and the New 

Directions for Families program, which is a comprehensive residential treatment program for women and their 

dependent children. New Directions has a capacity of sixteen families, with an expected length of stay of 4 

months, followed by 4 months of outpatient continuing care. 

Finally, with respect to adult services, The Wright Center, which is a 22-bed transitional residential program 

for men and women, has been modified to serve clients with COD. In addition to these programs for adults, 

Arapahoe House offers an array of programs designed to meet the needs of adolescents, and all of these programs target young persons with COD. This continuum of adolescent services includes counselors who work 

onsite in 16 high schools across the metropolitan Denver area; outpatient services at two sites, including day 

treatment; and two intensive residential treatment centers: one comprising 20 beds for male and female adolescents and the other a center for 15 adolescent females. These residential treatment centers offer comprehensive 

substance abuse and mental health treatment using an integrated model, and both sites contain an accredited 

school. 

clients are minimal to nonexistent, especially in those programs serving very resistant 

or hard-to-reach clients. 

•Practical assistance in life management. 

This feature incorporates case management 

activities that facilitate linkages with support services in the community. While the 

role of a counselor in the ACT approach 

includes standard counseling, in many 

instances substantial time also is spent on 

life management and behavioral management matters. 

154 Traditional Settings and Models 
Making ACT Work 

Source: Wingerson and Ries 1999. 

Team cohesion and smooth functioning are critical to success. The ACT multidisciplinary team has shared 

responsibility for the entire defined caseload of clients and meets frequently (ideally, teams meet daily) to 

ensure that all members are fully up-to-date on clinical issues. While team members may play different roles, 

all are familiar with every client on the caseload. Additionally, the ACT model includes the clients’ family and 

friends within treatment services. 

•Close monitoring. For some clients, especially those with SMI, close monitoring is 

required. 

This can include (Drake et al. 1993): 

– Medication supervision and/or management 

– Protective (representative) payeeships 

– Urine drug screens 

•Counseling. The nature of the counseling 

activity is matched to the client’s motivation 

and readiness for treatment. 

• Crisis intervention. This is provided during 

extended service hours (24 hours a day, ideally through a system of on-call rotation). 

Key modifications for 

integrating COD 

When working with a client who has COD, the 

goals of the ACT model are to engage the client 

in a helping relationship, to assist in meeting 

basic needs (e.g., housing), to stabilize the 

client in the community, and to provide direct 

and integrated substance abuse treatment and 

mental health services. The standard ACT 

model as developed by Test (1992) has been 

modified to include treatment for persons who 

have substance use disorders as well as mental 

disorders (Stein and Santos 1998). The key elements in this evolution have been 

•The use of direct substance abuse treatment 

interventions for clients with COD (often 

through the inclusion of a substance abuse 

treatment counselor on the multidisciplinary 

team) 

•A team focus on clients with COD (Drake et 

al. 1998a) 

•COD treatment groups (Drake et al. 1998a) 

•Modifications of traditional mental health 

interventions, including a strong focus on 

the relationships between mental health and 

substance use issues (e.g., providing skills 

training that focuses on social situations 

involving substance use [Drake and Mueser 

2000]) 

Substance abuse treatment strategies are related to the client’s motivation and readiness for 

treatment and include 

• Enhancing motivation (for example, through 

use of motivational interviewing) 

• Cognitive–behavioral skills for relapse prevention 

• 12-Step programming, including use of the 

peer recovery community to strengthen supports for recovery 

• Psychoeducational instruction about addictive disorders 

For clients who are not motivated to achieve 

abstinence, motivational approaches are structured to help them recognize the impact of substance use on their lives and on the lives of 

those around them. Therapeutic interventions 

are modified to meet the client’s current stage 

of change and receptivity. 

Populations served 

When modified as described above to serve 

clients with COD, the ACT model is capable of 

including clients with greater mental and functional disabilities who do not fit well into many 

traditional treatment approaches. The characteristics of those served by ACT programs for 

Traditional Settings and Models 155 
Nine Essential Features of ACT 

Source: Drake et al. 1998a. 

1. Services provided in the community, most frequently in the client’s living environment 

2. Assertive engagement with active outreach 

3. High intensity of services 

4. Small caseloads 

5. Continuous 24-hour responsibility 

6. Team approach (the full team takes responsibility for all clients on the caseload) 

7. Multidisciplinary team, reflecting integration of services 

8. Close work with support systems 

9. Continuity of staffing 

COD include those with a substance use disorder and 

•Significant mental disorders 

•Serious and persistent mental illness 

•Serious functional impairments 

•Who avoided or did not respond well to traditional outpatient mental health services and 

substance abuse treatment 

•Co-occurring homelessness 

•Co-occurring criminal justice involvement 

(National Alliance for the Mentally Ill 

[NAMI] 1999) 

In addition to, and perhaps as a consequence 

of, the characteristics cited above, clients targeted for ACT often are high utilizers of expensive service delivery systems (emergency rooms 

and hospitals) as immediate resources for mental health and substance abuse services. 

Empirical evidence for ACT 

The ACT model has been researched widely 

as a program for providing services to people 

who are chronically mentally ill. The general 

consensus of research to date is that the ACT 

model for mental disorders is effective in 

reducing hospital recidivism and, less consistently, in improving other client outcomes 

(Drake et al. 1998a; Wingerson and Ries 

1999). 

Randomized trials comparing clients with 

COD assigned to ACT programs with similar 

clients assigned to standard case management 

programs have demonstrated better outcomes 

for ACT. ACT resulted in reductions in hospital use, improvement on clinician ratings of 

alcohol and substance abuse, lower 3-year 

posttreatment relapse rates for substance use, 

and improvements on measures of quality of 

life (Drake et al. 1998a; Morse et al. 1997; 

Wingerson and Ries 1999). It is important to 

note that ACT has not been effective in 

reducing substance use when the substance 

use services were brokered to other providers 

and not provided directly by the ACT team 

(Morse et al. 1997). Researchers also considered the cost-effectiveness of these interventions, concluding that ACT has better client 

outcomes at no greater cost and is, therefore, 

more cost-effective than brokered case management (Wolff et al. 1997). 

Other studies of ACT were less consistent in 

demonstrating improvement of ACT over 

other interventions (e.g., Lehman et al. 

1998). In addition, the 1998 study cited previously (Drake et al. 1998b) did not show differential improvement on several measures 

important for establishing the effectiveness of 

156 Traditional Settings and Models 
ACT with COD—that is, retention in treatment, self-report measures of substance 

abuse, and stable housing (although both 

groups improved). Drake notes that “drift” 

occurred in the comparison group; that is, 

elements of ACT were incorporated gradually 

into the standard case management model, 

which made it difficult to determine the differential effectiveness of ACT. Further analyses indicated that clients in high-fidelity ACT 

programs showed greater reductions in alcohol and drug use and attained higher rates of 

remissions in substance use disorders than 

clients in low-fidelity programs (McHugo et 

al. 1999). Nevertheless, ACT is a recommended treatment model for clients with COD, 

especially those with serious mental disorders, based on the weight of evidence. 

Intensive case management 

The earliest model of case management was primarily a brokerage model, in which linkages to 

services were forged based on the individual 

needs of each client, but the case 

manager did not provide formal 

clinical services. Over time, it 

became apparent that clinicians 

could provide more effective case 

management services; consequently, clinical case management 

largely supplanted the brokerage 

model. ICM emerged as a strategy 

in the late 1980s and early 1990s. 

It was designed as a thorough, 

long-term service to assist clients 

with SMI (particularly those with 

mental and functional disabilities 

and a history of not adhering to 

prescribed outpatient treatment) 

by establishing and maintaining 

linkages with community-based 

service providers. 

ICM is not a precisely defined 

term, but rather is used in the literature to describe an alternative 

to both traditional case management and ACT. The goals of the 

ICM model are to engage individuals in a trusting relationship, assist in meeting 

their basic needs (e.g., housing), and help them 

access and use brokered services in the community. The fundamental element of ICM is a low 

caseload per case manager, which translates 

into more intensive and consistent services for 

each client. TIP 27, Comprehensive Case 

Management for Substance Abuse Treatment 

(CSAT 1998b), contains more information on 

the history of case management, both how it 

has developed to meet the needs of clients in 

substance abuse treatment (including clients 

with COD) and specific guidelines about how to 

implement case management services. 

Program model 

ICM programs typically involve outreach and 

engagement activities, brokering of communitybased services, direct provision of some support/counseling services, and a higher intensity 

of services than standard case management. 

The intensive case manager assists the client in 

selecting services, facilitates access to these serAdvice to Administrators: 

Treatment Principles From ACT 

• Provide intensive outreach activities. 

• Use active and continued engagement techniques with 

clients. 

• Employ a multidisciplinary team with expertise in substance abuse treatment and mental health. 

• Provide practical assistance in life management (e.g., 

housing), as well as direct treatment. 

• Emphasize shared decisionmaking with the client. 

• Provide close monitoring (e.g., medication management). 

• Maintain the capacity to intensify services as needed 

(including 24-hour on-call, multiple visits per week). 

• Foster team cohesion and communication; ensure that all 

members of the team are familiar with all clients on the 

caseload. 

• Use treatment strategies that are related to the client’s 

motivation and readiness for treatment, and provide 

motivational enhancements as needed. 

Traditional Settings and Models 157 
vices, and monitors the client’s progress 

through services provided by others (inside or 

outside the program structure and/or by a 

team). Client roles in this model include serving 

as a partner in selecting treatment components. 

In some instances, the ICM model uses multidisciplinary teams similar to ACT. The composition of the ICM team is determined by the 

resources available in the agency implementing 

the programs. The team often includes a cluster-set of case managers rather than the specialists prescribed as standard components of 

the treatment model. The ICM team may offer 

services provided by ACT teams, including 

practical assistance in life management (e.g., 

housing) and some direct counseling or other 

forms of treatment. Caseloads are kept smaller 

than those in other community-based treatment 

models (typically, the client-to-counselor ratio 

ranges from 15:1 to 25:1), but larger than those 

in the ACT model. Because the case management responsibilities are so wide ranging and 

require a broad knowledge of local treatment 

services and systems, a typically trained counselor may require some retraining and/or close, 

instructive supervision in order to serve effectively as a case manager. 

Treatment activities and 

interventions 

Examples of ICM activities and interventions 

include 

•Engaging the client in an alliance to facilitate the process and connecting the client 

with community-based treatment programs 

•Assessing needs, identifying barriers to 

treatment, and facilitating access to treatment 

•Offering practical assistance in life management and facilitating linkages with support services in the community 

•Making referrals to treatment programs 

and services provided by others in the community (see TIP 27 [CSAT 1998b] for guidance on establishing linkages for service 

provision and interagency cooperation) 

•Advocating for the client with treatment 

providers and service delivery systems 

•Monitoring progress 

•Providing counseling and support to help 

the client maintain stability in the community 

•Crisis intervention 

•Assisting in integrating treatment services 

by facilitating communication between service providers 

Key modifications of ICM for 

co-occurring disorders 

Key ICM modifications from basic case management for clients with COD include 

• Using direct interventions for clients with 

COD, such as enhancing motivation for treatment and discussing the interactive effects of 

mental and substance use disorders 

• Making referrals to providers of integrated 

substance abuse and mental health services 

or, if integrated services are not available or 

accessible, facilitating communication 

between separate brokered mental health 

and substance abuse service providers 

• Coordinating with community-based services 

to support the client’s involvement in mutual 

self-help groups and outpatient treatment 

activities 

Empirical evidence 

The empirical study of ICM for COD is not as 

extensive or as clarifying as the research on 

ACT; however, some studies do provide 

empirical support. ICM has been shown to be 

effective in engaging and retaining clients with 

COD in outpatient services and to reduce 

rates of hospitalization (Morse et al. 1992). 

Further, treatments combining substance 

abuse counseling with intensive case management services have been found to reduce substance use behaviors for this population in 

terms of days of drug use, remission from 

alcohol use, and reduced consequences of 

substance use (Bartels et al. 1995; Drake et 

al. 1993, 1997; Godley et al. 1994). The con158 Traditional Settings and Models 
tinued use and further develop­


ment of ICM for COD is indicat­


ed based on its overall utility 

and modest empirical base. 

Comparison of ACT 

and ICM 

Similarities between ACT 

and ICM 

Both ACT and ICM share the following key activities and interventions: 

•

•

•

•

•

•

•

•

•

•

•

Focus on increased treatment 

participation 

Client management 

Abstinence as a long-term goal, 

with short-term supports 

Stagewise motivational interventions 

Psychoeducational instruction 

Cognitive–behavioral relapse prevention 

Encouraging participation in 12-Step 

programs 

Supportive services 

Skills training 

Crisis intervention 

Individual counseling 

Differences between 

ACT and ICM 

ACT is more intensive than most ICM 

approaches. The ACT emphasis is on developing a therapeutic alliance with the client and 

delivery of service components in the client’s 

home, on the street, or in program offices 

(based on the client’s preference). ACT services, as described by NAMI (1999), are provided predominantly by the multidisciplinary 

staff of the ACT team (typically, 75 percent of 

services are team provided), and the program 

often is located in the community. Most ACT 

programs provide services 16 hours a day on 

weekdays, 8 hours a day on weekends, plus oncall crisis intervention, including visits to the 

client’s home at any time, day or night, with 

the capacity to make multiple visits to a client 

on any given day. Caseloads usually are 12:1. 

ICM programs typically include fewer hours of 

direct treatment, though they may include 24­

hour crisis intervention; the focus of ICM is on 

brokering community-based services for the 

client. ICM caseloads range up to 25:1. 

The ACT multidisciplinary team has shared 

responsibility for the entire defined caseload of 

clients and meets frequently (ideally, teams 

meet daily) to ensure that all members are fully 

up-to-date on clinical issues. While team members may play different roles, all are familiar 

with every client on the caseload. The nature of 

ICM team functioning is not as defined, and 

cohesion is not necessarily a focus of team functioning; the ICM team can operate as a loose 

federation of independent case managers or as 

a cohesive unit in a manner similar to ACT. 

Also, the ACT model has been developed to 

include the clients’ family and friends within 

treatment services (Wingerson and Ries 1999), 

which is not necessarily true for ICM models. 

Advice to Administrators: 

Treatment Principles From ICM 

• 

• 

• 

• 

• 

• 

• 

Select clients with greater mental and functional disabilities who are resistant to traditional outpatient treatment 

approaches. 

Employ low caseload per case manager to accommodate 

more intensive services. 

Assist in meeting basic needs (e.g., housing). 

Facilitate access to and utilization of brokered community-based services. 

Provide long-term support, such as counseling services. 

Monitor the client’s progress through services provided 

by others. 

Use multidisciplinary teams. 

ICM most frequently involves the coordination of services across different systems 

and/or over extended periods of time, while 

ACT integrates and provides treatment for 

COD within the team. As a consequence, 

while advocacy with other providers is a 

major component of ICM, advocacy in ACT 

focuses on ancillary services. Additionally, 

Traditional Settings and Models 159 
the ACT multidisciplinary team approach to 

treatment places greater emphasis on providing integrated treatment for clients with COD 

directly, assuming that the team members 

include both mental health and substance 

abuse treatment counselors and are fully 

trained in both approaches. 

Recommendations for 

extending ACT and ICM in 

substance abuse treatment 

settings 

It is not self-evident that ACT and ICM models 

translate easily to substance abuse settings. The 

consensus panel offers the following six key recommendations for successful use of ACT and 

ICM in substance abuse settings with clients 

who have COD: 

1.		Use ACT and ICM for clients who require 

considerable supervision and support. 

ACT is a treatment alternative for those 

clients with COD who have a history of 

sporadic adherence with continuing care 

or outpatient services and who require 

extended monitoring and supervision (e.g., 

medication monitoring or dispensing) and 

intensive onsite treatment supports to sustain their tenure in the community (e.g., 

criminal justice clients). For this subset of 

the COD population, ACT provides accessible treatment supports without requiring 

return to a residential setting. The typical 

ICM program is capable of providing less 

intense levels of monitoring and supports, 

but can still provide these services in the 

client’s home on a more limited basis. 

2. Develop ACT and/or ICM programs selectively to address the needs of clients with 

SMI who have difficulty adhering to treatment regimens most effectively. ACT, 

which is a more complex and expensive 

treatment model to implement compared 

with ICM, has been used for clients with 

SMI who have difficulty adhering to a 

treatment regimen. Typically, these are 

among the highest users of expensive (e.g., 

emergency room, hospital) services. ICM 

programs can be used with treatmentresistant clients who are clinically and 

functionally capable of progressing with 

much less intensive onsite counseling and 

less extensive monitoring. 

3. 	Extend and modify ACT and ICM for 

other clients with COD in substance abuse 

treatment. With their strong tradition in 

the mental health field, particularly for 

clients with SMI, ACT and ICM are attractive, accessible, and flexible treatment 

approaches that can be adapted for individuals with COD. Components of these 

programs can be integrated into substance 

abuse treatment programs. 

4. 	Add substance abuse treatment components to existing ACT and ICM programs. 

Incorporating methods from the substance 

abuse treatment field, such as substance 

abuse education, peer mutual self-help, 

and greater personal responsibility, can 

continue to strengthen the ACT approach 

as applied to clients with COD. The degree 

of integration of substance abuse and mental health components within ACT and 

ICM is dependent upon the ability of the 

individual case manager/counselor or the 

team to provide both services directly or 

with coordination. 

5. 	Extend the empirical base of ACT and 

ICM to further establish their effectiveness 

for clients with COD in substance abuse 

treatment settings. The empirical base for 

ACT derives largely from its application 

among people with SMI and needs to be 

extended to establish firm support for the 

use of ACT across the entire COD population. In particular, adding an evaluation 

component to new ACT programs in substance abuse settings can provide documentation currently lacking in the field 

concerning the effectiveness and cost benefit of ACT in treating the person who 

abuses substances with co-occurring men160 Traditional Settings and Models 
tal disorders in substance abuse treatment 

settings. The limitations of ICM have been 

listed above. The use of ACT or ICM 

should turn on the assessed needs of the 

client. 

Residential Substance 

Abuse Treatment 

Programs for Clients 

With COD 

Background and Effectiveness 

Residential treatment for substance abuse 

comes in a variety of forms, including longterm (12 months or more) residential treatment 

facilities, criminal justice-based programs, 

halfway houses, and short-term residential programs. The long-term residential substance 

abuse treatment facility is the primary treatment site and the focus of this section of the 

TIP. Historically, residential substance abuse 

treatment facilities have provided treatment to 

clients with more serious and active substance 

use disorders but with less SMI. Most providers 

now agree that the prevalence of people with 

SMI entering residential substance abuse treatment facilities has risen. 

Prevalence 

As noted, mental disorders have been observed 

in an increasing proportion of clients in many 

substance abuse treatment settings (De Leon 

1989; Rounsaville et al. 1982a). Compared to 

the rates found in clients in the outpatient programs of DATOS, slightly higher rates of antisocial personality disorder, and roughly similar 

rates of major depressive episode and generalized anxiety disorder, were found among adult 

clients admitted to the long-term residential 

programs that were part of DATOS (Flynn et 

al. 1996; see also Figure 1-2 in chapter 1 of this 

TIP). Of course, those admitted to long-term 

residential care tended to have more severe 

substance abuse problems. Additionally, in the 

year prior to admission to treatment, clients in 

long-term residential care reported the highest 

rate of past suicidal thoughts or attempts (23.6 

percent) as compared to outpatient drug-free 

(19.3 percent) and outpatient methadone treatment (16.6 percent). Only the suicide thoughts 

and attempts rate for clients admitted to shortterm inpatient treatment was higher (31.0 percent) (Hubbard et al. 1997, Table 2). This evidence points to the need for a programmatic 

response to the problems posed by those with 

COD who enter residential treatment settings. 

Historically, res­


idential substance abuse

treatment facilities have provided treatment to 

clients with 

more serious

and active

substance use

disorders but 


with less SMI. 


Empirical evidence of 

effectiveness 

Evidence from a number of large-scale, longitu­


dinal, national, multisite treatment studies has 


established the effectiveness of residential sub­


stance abuse treatment (Fletcher et al. 1997; 


Hubbard et al. 1989). In general, these studies 


have shown that residential substance abuse 


treatment results in 


significant improve­


ment in drug use, 


crime, and employment. 


The most recent of 

these national 

efforts is NIDA’s 

DATOS (Fletcher et 

al. 1997). The 

DATOS study 

involved a total of 

10,010 adult clients, 

including many 

minorities, admitted 

between 1991 and 

1993 to short-term 

inpatient substance 

abuse treatment 

programs, residential TCs, outpatient 

drug-free programs, 

or outpatient 


methadone mainte­


nance programs 

across 11 cities 


(Chicago, Houston, 

Miami, 


Minneapolis, 


Traditional Settings and Models 161 
Newark, New Orleans, New York, Phoenix, 

Pittsburgh, Portland, and San Jose). Of the 

4,229 clients eligible for follow-up and interviewed at intake, 2,966 were re-interviewed 

successfully after treatment (Hubbard et al. 

1997). 

Encouragingly, even with this high prevalence 

of clients with COD, DATOS study participants displayed positive outcomes for substance use and other maladaptive behaviors 

in the first year after treatment. Because 

studies of populations that abuse substances 

have shown that those who remain in treatment for at least 3 months have more favorable outcomes, a critical retention threshold 

of at least 90 days has been established for 

residential programs (Condelli and Hubbard 

1994; Simpson et al. 1997b, 1999). Persons 

admitted to residential programs likely have 

the most severe problems, and those remaining beyond the 90-day threshold have the 

most favorable outcomes (Simpson et al. 

1999). 

Legal pressure and internal motivation among 

clients in residential programs have been 

associated with retention beyond the 90-day 

threshold (Knight et al. 2000). This relationship between legal pressure and retention 

supports practices that encourage court referrals to residential treatment for drug-involved 

persons (Hiller et al. 1998). Broome and colleagues (1999) found that hostility was related 

to a lower likelihood of staying in residential 

treatment beyond the 90-day threshold, but 

depression was associated with a greater likelihood of retention beyond the threshold. 

Designing Residential 

Programs for Clients With 

COD 

To design and develop services for clients with 

COD, a series of interrelated program activities 

must be undertaken, as discussed below. While 

the MTC described in detail later in this chapter is used frequently as a frame of reference 

throughout this discussion, these observations 

are applicable both to such TCs and to other 

residential programs that might be developed 

for COD. 

Intake 

Chapter 4 provides a full discussion of screening and assessment. This section will address 

intake procedures relevant to persons with 

COD in residential substance abuse treatment 

settings. The four interrelated steps of the relevant intake process include: 

1.		Written referral. Referral information from 

other programs or services can include the 

client’s psychiatric diagnosis, history, current level of mental functioning, medical 

status (including results of screening for 

tuberculosis, HIV, STDs, and hepatitis), 

and assessment of functional level. Referrals 

also may include a psychosocial history and 

a physical examination. 

2.		Intake interview. An intake interview is 

conducted at the program site by a counselor or clinical team. At this time, the 

referral material is reviewed for accuracy 

and completeness, and each client is interviewed to determine if the referral is 

appropriate in terms of the history of mental and substance abuse problems. The 

client’s residential and treatment history is 

reviewed to assess the adequacy of past 

treatment attempts. Finally, each client’s 

motivation and readiness for change are 

assessed, and the client’s willingness to 

accept the current placement as part of 

the recovery process is evaluated. 

Screening instruments, such as those 

described in chapter 4, can be used in conjunction with this intake interview. 

3. 	Program review. Each client should 

receive a complete description of the program and a tour of the facility to ensure 

that both are acceptable. This review 

includes a description of the daily operation of the program in terms of groups, 

activities, and responsibilities; a tour of 

the physical site (including sleeping 

arrangements and communal areas); and 

162 Traditional Settings and Models 
an introduction to some of the clients who 

are already enrolled in the program. 

4. Team meeting. At the end of the intake 

interview and program review, the team 

meets with the client to arrive at a decision 

concerning whether the referred client 

should be admitted to the program. The 

client’s receptivity to the program is considered and additional information (e.g., 

involvement with the justice system, suicide attempts) is obtained as needed. It 

should be noted that the decisionmaking 

process is inclusive; that is, a program 

accepts referrals as long as they meet the 

eligibility criteria, are not currently a danger to self or others, do not refuse medication, express a readiness and motivation 

for treatment, and accept the placement 

and the program as part of their recovery 

process. 

Assessment 

Once accepted into the program, the client goes 

through an assessment process that should 

include five areas: 

1.		Substance abuse evaluation. The substance abuse evaluation consists of assessing age at first use, primary drugs used, 

patterns of drug and alcohol use, and 

treatment episodes. This information can 

be augmented by some basic standard data 

collection method such as the Addiction 

Severity Index (ASI). 

2. Mental health evaluation. Upon placement 

in a residential facility, it is desirable to 

have a psychiatrist, psychologist, or other 

qualified mental health professional evaluate each client’s mental status, cognitive 

functioning, diagnosis, medication requirements, and the need for individual mental 

health services. If individual treatment is 

indicated, it is integrated with residential 

treatment via contact among the client, the 

case manager, and the therapist. 

3. 	Health and medical evaluation. Referral 

information contains the results of recent 

medical examinations required for placement. All outstanding medical, dental, and 

other health issues, including infectious 

diseases, especially HIV and hepatitis, 

should be addressed early in the program 

through affiliation agreements with 

licensed medical facilities. Each client 

should receive a complete medical evaluation within 30 days of entry into the program. 

4. 	Entitlements. The counselor should assess 

the status of each client’s entitlements 

(e.g., Supplemental Security Income 

[SSI], Medicaid, etc.) and assist clients in 

completing all necessary paperwork to 

ensure maximum benefits. However, care 

must be taken 

not to jeopardize


a client’s eligibil-
 

ity for SSI by



inadvertently



mischaracterizing the client’s 

disability as substance abuse primary. 

5. 	Client status. 

Staff members 

assess clients’ 

status as they 

enter treatment, 

including personal strengths,



goals, family,
 


and social sup­


ports. A key



assessment



weighs the 

client’s readiness and motivation for 

change. 

A successful

engagement program helps 

clients to view 

the treatment 

facility as an 

important

resource.

Engagement 

The critical issue for clients with COD is 

engaging them in treatment so that they can 

make use of the available services. A successful engagement program helps clients to view 

the treatment facility as an important 

resource. To accomplish this, the program 

must meet essential needs and ensure psychiatric stabilization. Residential treatment programs can accomplish this by offering a wide 

Traditional Settings and Models 163 
range of services that include both targeted 

services for mental disorders and substance 

abuse and a variety of other “wraparound” 

services including medical, social, and workrelated activities. The extensiveness of residential services has been well documented 

(Etheridge et al. 1997; McLellan et al. 1993; 

Simpson et al. 1997a). 

The interventions to promote engagement 

described in Figure 6-1 incorporate therapeutic community-oriented methods described in 

other studies (Items 1, 3, 5–7) (De Leon 

1995), as well as strategies employed and 

found clinically useful in non-TC programs 

(Items 2 and 4). This approach holds promise 

for expanding treatment protocols for TC and 

many non-TC programs to permit wider 

treatment applicability. 

Continuing care 

Returning to life in the community after residential placement is a major undertaking for 

clients with COD, with relapse an ever-present danger. The long-term nature of mental 

disorders and substance abuse requires continuity of care for a considerable duration of 

time—at least 24 months (see, e.g., Drake et 

al. 1996b, 1998b). The goals of continuing 

care programming are sustaining abstinence, 

continuing recovery, mastering community 

living, developing vocational skills, obtaining 

gainful employment, deepening psychological 

understanding, increasing assumption of 

responsibility, resolving family difficulties, 

and consolidating changes in values and identity. The key services are life skills education, 

relapse prevention, 12-Step or double trouble 

groups, case management (especially for 

housing) and vocational training and employment. A recent study (Sacks et al. 2003a) provided preliminary evidence that a continuing 

care strategy using TC-oriented supported 

housing stabilizes gains in drug use and crime 

prevention, and is associated with incremental improvement in psychological functioning 

and employment. 

Discharge planning 

Discharge planning follows many of the same 

procedures discussed in the section on outpatient treatment. However, there are several 

other important points for residential programs: 

• Discharge planning begins upon entry into 

the program. 

• The latter phases of residential placement 

should be devoted to developing with the 

client a specific discharge plan and beginning 

to follow some of its features. 

• Discharge planning often involves continuing 

in treatment as part of continuity of care. 

• Obtaining housing, where needed, is an integral part of discharge planning. 

Implementing Residential 

Programs 

The literature contains many descriptions of 

programs that are employed in the various 

agencies but far fewer descriptions of how to 

design and implement these programs. Figure 

6-2 (p. 166) identifies some principles found 

effective in designing and implementing residential programs. 

Staffing 

Developing a new treatment model places 

unique demands on staff. Staff for clients with 

COD should contain a substantial proportion 

of both mental health and substance abuse 

treatment providers, include both recovering 

and nonrecovering staff, and be culturally 

competent with regard to the population in 

treatment. A typical 25-bed residential program should consist of about 15 staff, as follows: 

• Program director (preferably with an 

advanced degree in the human service field 

or with at least 5 years’ experience in substance abuse treatment, including at least 3 

years of supervisory experience), a secretary, 

a program supervisor (preferably with a 

164 Traditional Settings and Models 
Figure 6-1 

Engagement Interventions 

Source: Adapted from Sacks et al. 2002. 

Item Element Description 

1 Client Assistance Counseling •Emphasizes client responsibility, coaching and 

guiding the client, and using the client’s senior 

peers to provide assistance 

2 Medication •Begins with mental health assessment and medication prescription, then monitors for medication adherence, side effects, and effectiveness 

3 Active Outreach and Continuous Orientation •Builds relationships and enhances program 

compliance and acceptance through multiple 

staff contacts 

4 Token Economy • Awards points (redeemable for tangible 

rewards such as phone cards, candy, toiletries) 

for positive behaviors including medication 

adherence, abstinence, attendance at program 

activities, follow-through on referrals, completing assignments, and various other activities essential to the development of commitment 

5 Pioneers—Creating a Positive Peer Culture • Facilitates program launch by forming a 

seedling group of selected residents (pioneers) 

to transmit the peer mutual self-help culture 

and to encourage newly admitted clients to 

make full use of the program 

6 Client Action Plan • Formulated by clients and staff to specify, 

monitor, and document client short-term goals 

under the premise that substantial accomplishments are achieved by attaining smaller objectives 

7 Preparation for Housing • Entitlements are obtained—a Section 8 application for housing is filed, available treatment 

and housing options are explored, work readiness skills are developed, and household management skills are taught 

Traditional Settings and Models 165 
Figure 6-2 

Principles of Implementation 

Source: Adapted from Sacks et al. 1997b. 

How to organize 

• 

•

Identify the key person responsible for the successful implementation of the program. 

Use a field demonstration framework in which there is cross-fertilization between program design and empirical 

data. 

How to integrate with a system 

• 

• 

Follow system policy, guidelines, and constraints. 

Involve system stakeholders. 

How to integrate in an agency 

• 

•

Select an agency that displays organizational readiness and encourages program change. 

Form collaborative relationships at all levels of the organization, including both program and executive staff. 

How to design, launch, and implement 

•

• 

• 

Develop a planning group of key stakeholders that meets regularly. 

Ensure client and staff orientation to all program elements. 

Provide training and technical assistance in the context of implementation. 

bachelor’s degree), and 10 line staff (with 

high school diplomas or associate’s degrees) 

•A clinical coordinator, a nurse practitioner 

(half-time), an entitlements counselor (halftime), and a vocational rehabilitation counselor (half-time) 

•Consultive and/or collaborative arrangements 

for medical, psychiatric, and psychological 

input or care 

The optimal staffing ratio for morning, afternoon, and night shifts is 3:1, 3:1, and 8:1, 

respectively. The critical position is the clinical 

coordinator who will direct program implementation. 

Training 

Initial training 

To implement a new initiative such as the 

multicomponent MTC requires both initial 

training and continuing technical assistance. 

Learning should be both a didactic and experiential activity. The initial training for an 

MTC, conducted at the program site for 5 

days before program launch, provides a 

model of structure and process that can be 

applied in other TC and non-TC settings. The 

training includes an overview of the philosophy, history, and background of the TC 

approach; a review of structure, including the 

daily regimen, role of staff, role of peers, 

peer work structure, privileges, and sanctions; and a review of treatment process, 

including a description of the stages and 

phases of treatment. This curriculum also 

includes special training in the assessment 

and treatment of clients with COD and in the 

key modifications of the TC for clients with 

COD (see Figure 6-3). Once established, the 

flagship program becomes the model for subsequent experiential training. 

166 Traditional Settings and Models 
Figure 6-3 

Sample Training and Technical Assistance Curriculum 

What is a TC? • 

• 

• 

Describes the theory, principles, and methods of the TC 

Presents the TC perspective of four views: person, disorder, recovery, and 

“right living” 

Describes the fundamentals of the TC approach with an emphasis on community-as-method; i.e., the community is the healing agent 

What do we know about the 

treatment of people with 

COD? 

• 

• 

• 

Reviews the literature on the increased prevalence of clients with COD in the 

mental health services, substance abuse treatment, and criminal justice systems 

Presents a selected review and classification of treatment approaches and 

principles; provides a review of the research literature and its implications 

for practice 

Describes research establishing the effectiveness of MTCs for clients with 

COD 

What is an MTC? • 

• 

Describes the seven main modifications of the TC for clients with COD 

Elaborates key changes in structure, process, and interventions of MTCs for 

clients with COD 

How do we assess/diagnose • 

• 

• 

• 

• 

• 

Describes the main signs and symptoms of SMI for schizophrenia, major 

the client with COD? depression, and mania 

Presents critical differences between Axis I and Axis II disorders (see the 

DSM-IV-TR) and their implications for program design 

Describes the 10 main characteristics of populations of people with substance 

use disorders 

Presents a classification of criminal behavior and criminal thinking 

Presents three clinical instruments for assessing mental disorders, substance 

abuse, and danger profile 

Presents empirical data on profiles of clients with COD 

How do we start/implement 

the program? 

• 

• 

• 

• 

• 

• 

Presents six guidelines for successful program implementation 

Provides practical advice on how to recruit, select, and initially evaluate 

Emphasizes how to establish the TC culture 

Describes six techniques for engaging the client in treatment 

Presents empirical data from staff studies on the process of change 

Develops a sequence for implementing the core TC elements 

Traditional Settings and Models 167 
Figure 6-3 (continued) 

Sample Training and Technical Assistance Curriculum 

What are the main interventions and activities of 

the TC? 

• 

• 

• 

Provides a complete list and brief discussion of all TC interventions in four 

areas: community enhancement (e.g., morning meeting), therapeutic/educative 

(e.g., conflict resolution groups, interpersonal skills training, medication/medication monitoring), community/clinical management (e.g., learning experiences), and work/other (e.g., peer work hierarchy) 

Delineates the interventions for both the residential and continuing care 

components 

Uses illustrations to teach three main interventions 

How do clients change? • 

• 

• 

• 

Presents the stages and phases of TC programs 

Describes the domains and dimensions of change 

Describes an instrument for measuring change 

Presents empirical data from staff studies on the process of change 

What is the role of the • 

• 

• 

• 

Describes the staffing patterns and job responsibilities of TC staff 

staff? Discusses the role of mental health, substance abuse, and criminal justice staff 

Uses exercises to establish teamwork and “esprit de corps” 

Provides the major cross-training experiences 

What is it like to be in a 

TC? 

• 

• 

• 

• 

Discusses the “nuts and bolts” of TC operations 

Provides a description of a typical day in the life of a TC resident 

Demonstrates a typical schedule for a TC day/week 

Addresses the concerns and issues of non-TC trained staff 

Ongoing training and technical 

assistance 

Training and technical assistance take place in 

the field; both are direct and immediate. Staff 

members learn exactly how to carry out program activities by participating in the activities. 

Technical assistance begins with a discussion of 

TC methods over a period of time (usually several weeks) before implementation, followed by 

active illustration during the initiation period 

(several weeks to several months). Supervisors 

hold briefing and debriefing sessions before 

and after each group activity, a process that 

continues for several months. As staff members 

begin to lead new activities, technical assistance 

staff members provide guidance for a period of 

several weeks. Monitoring continues until staff 

demonstrate competency (which takes several 

weeks, on average), as established by supervisory ratings. Thereafter, quarterly reviews 

ensure continued staff competency and fidelity 

of program elements to TC principles and 

methods. Training in the MTC model and its 

implementation has been conducted nationally 

by National Development and Research 

Institutes as a part of grant supported activities 

on NIDA- and SAMHSA-funded projects at no 

cost to the provider agencies. Other TC agencies (e.g., Gaudenzia, Odyssey House in New 

York) have also developed this model and 

either provide training or have the capacity to 

provide training. SAMHSA’s Co-Occurring 

Center for Excellence affords a unique opportunity for training and the further dissemination of the MTC and other evidence- and consensus-based practices recommended by the 

consensus panel. See also appendix I for a list 

of training resources. 

168 Traditional Settings and Models 
Evaluating Residential 

Programs 

The model outlined in the section on outpatient 

services can be applied here. Program evaluation for use by administrators to improve their 

programs also can consist of assessing performance standards such as bed or occupancy 

rates, program retention, average duration of 

stay, existence of service plans, and referral 

rates to continuing care. These will be evaluated by comparing standards (to be established 

by each program) to actual data. Such measures are available in almost all programs and 

require very little in the way of additional 

resources. In addition, client satisfaction surveys and focus groups are useful in providing 

feedback from the perspective of the client and 

his or her family. 

The efficacy of programs can be evaluated by 

determining change from pre- to post-treatment 

on basic measures of substance abuse and psychological functioning. Chapter 4 outlines a 

variety of measures that are available for this 

purpose including the ASI (McLellan et al. 

1985), the Global Appraisal of Individual 

Needs (Dennis 2000), the Symptom Checklist90 (Derogatis and Spencer 1982; Derogatis et 

al. 1973) and the Beck Depression Inventory 

(Beck and Steer 1987). These measures are relatively easy to use and can be employed even in 

substance abuse treatment programs with limited resources. The highest level of evaluation 

involves systematic research study; such efforts 

Special Issue: The Use of Confrontation in Residential 

Substance Abuse Treatment 

Confrontation is used commonly in residential substance abuse treatment. De Leon (2000b) presents a full 

description of confrontation that serves as the basis of this discussion. De Leon defines confrontation as a 

form of interpersonal exchange in which individuals present to each other their observations of, and reactions to, behaviors and attitudes that are matters of concern and that should change. In TC-oriented programs, confrontation is used informally in peer interactions, and formally in the encounter group process. 

The primary objective of confrontational communication simply is to raise the individual’s awareness of how 

his or her behavior and attitudes affect others. Compassionate conversation, mutual sharing, and other supportive communications and interactions balance properly implemented confrontational exchanges. 

Confrontation presents “reality” to individuals. Reality in this sense consists of peer reactions to each other’s 

behavior and attitudes: teaching clients to say it as they see it and to say it honestly. Peer reactions include 

thoughts as well as the expression of honest feelings that enhance the credibility of the observations. These 

emotional expressions may be uncomfortable (e.g., hurt, anger, disappointment, fear, sadness) or comfortable (e.g., love, hope, happiness, encouragement, optimism). Appropriate intensity of emotions always is 

delivered with responsible concern. Thus, the observations and reactions of a confrontation may address negative “reality” and also affirm the “reality” of positive changes in behaviors and attitudes in individuals as 

they are perceived by others. 

Confrontation skills and their application in encounter group are learned through staff training. There are 

tools and rules that enhance the therapeutic utility of confrontation in particular and the encounter group 

process in general. Thus, clients and staff must be trained in the proper use of confrontation. 

The consensus panel notes that in working with individuals who have COD, the conflict resolution group 

replaces the encounter group, and the conflict resolution group is described below in the section on MTCs. In 

brief, the conflict resolution group has many of the same goals as the encounter group but modifies some of 

the features (especially the degree of emotional intensity) that characterize the confrontation employed in 

standard encounter groups as described by De Leon above. 

Traditional Settings and Models 169 
usually require partnerships with research



investigators.



Sustaining Residential 

Programs 

One important vehicle for sustaining the residential program is through the development of 

a Continuous Quality Improvement (CQI) plan. 

The goal of CQI is to assess and ensure that the 

program meets 

established standards. It is a participatory process led 

by internal program 

staff with consultation from experts 

who use both quantitative and qualitative information to

monitor and review 

program status and

to develop action 

plans for program 

improvements and 

refinements. For 

quality control, the 

CQI staff uses observation, key informant interviews, 

resident focus

groups, standardized instruments,

and staff review. 

CQI is a management plan for sustaining program

quality, for ensuring 

that programs are 

responsive to client 

needs, and for maintaining performance 

standards. 

A sample CQI plan for an MTC in residential 

facilities, applicable with modified instruments 

to other residential programs, is as follows: 

•Fidelity of program implementation to program design and TC standards. Program 

fidelity (i.e., assurance that the key elements/interventions of the TC are present) 

may be tested by administration of the TC 

Scale of Essential Elements Questionnaire 

(SEEQ) (Melnick and De Leon 1999). Any 

scores that fall below the level of “meets the 

standard” will trigger discussion and appropriate adjustments. 

•Delivery of actual program activities/elements. Appropriate measures for success 

include (1) the delivery of an established 

number of program hours per day or week, 

as measured by a review of staff schedules 

and information systems report; (2) the 

delivery of an established level of specific 

groups and activities, as assessed by program schedules and program management 

information system activity reports; and (3) 

satisfactory concordance rate between program activities as designed and as delivered. This rate may be assessed using the 

Program Monitoring Form and the TC 

Scale of Essential Elements Questionnaire 

(Melnick and De Leon 1999). 

•Presence of a therapeutic environment. The 

use of community as the healing agent, the 

existence of trust in interpersonal relationships, and the perception of the TC program as a place to facilitate recovery and 

change, together constitute a therapeutic 

environment. The extent to which these elements exist may be established by participant observation, interviews, and focus 

groups. 

The goals of the		

TC are to promote abstinence 

from alcohol 

and illicit drug 

use, to decrease 

antisocial		

behavior, and to 

effect a global 

change in 

lifestyle, including attitudes and 

values.		

Therapeutic Communities 

The goals of the TC are to promote abstinence from alcohol and illicit drug use, to 

decrease antisocial behavior, and to effect a 

global change in lifestyle, including attitudes 

and values. The TC views drug abuse as a 

disorder of the whole person, reflecting problems in conduct, attitudes, moods, values, 

and emotional management. Treatment focuses on drug abstinence, coupled with social 

and psychological change that requires a multidimensional effort, involving intensive 

mutual self-help typically in a residential set170 Traditional Settings and Models 
ting. At the time of this writing, the duration 

of residential TC treatment typically is about 

12 months, although treatment duration has 

been decreasing under the influence of managed care and other factors. In a definitive 

book titled The Therapeutic Community: 

Theory, Model, and Method, De Leon (2000b) 

has provided a full description of the TC for 

substance abuse treatment to advance 

research and guide training, practice, and 

program development. 

The effectiveness of TCs in reducing drug use 

and criminality has been well documented in 

a number of program-based and multisite 

evaluations. In general, positive outcomes are

related directly to increased length of stay in 

treatment (De Leon 1984; Hubbard et al. 

1984; Simpson and Sells 1982). Short- and 

long-term follow-up studies show significant 

decreases in alcohol and illicit drug use, 

reduced criminality, improved psychological 

functioning, and increased employment 

(Condelli and Hubbard 1994; De Leon 1984; 

Hubbard et al. 1997; Simpson and Sells 

1982). 

In terms of psychological functioning, clients 

demonstrate improvement in psychological 

well-being after treatment (Brook and 

Whitehead 1980; Carroll and McGinley 1998; 

De Leon 1984, 1989; De Leon and Jainchill 

1982; Kennard and Wilson 1979). Research 

findings indicate that psychological status 

improves during treatment, with larger 

changes in self-esteem, ego strength, socialization, and depression, and smaller changes in 

long-standing characteristics such as personality disorders (De Leon and Jainchill 1982). 

Modified therapeutic communities for clients with COD 

The MTC approach adapts the principles and 

methods of the TC to the circumstances of the 

COD client. The illustrative work in this area 

has been done with people with COD, both 

men and women, providing treatment based 

on community-as-method—that is, the community is the healing agent. This section 

focuses on the MTC as the potent residential 

model developed within the substance abuse 

treatment field; most of this section applies to 

both TC and other residential substance 

abuse treatment programs. A complete 

description of the MTC for clients with COD, 

including treatment manuals and guides to 

implementation, can be found in other writings (e.g., De Leon 1993a; Sacks et al. 1997a, 

b, 1999). 

Treatment activities/interventions 

All program activities and interactions, singly 

and in combination, are designed to produce 

change. Interventions are grouped into four 

categories—community enhancement (to promote affiliation with the TC community), therapeutic/educative (to promote expression and 

instruction), community/clinical management 

(to maintain personal and physical safety), and 

vocational (to operate the facility and prepare 

clients for employment). Implementation of the 

groups and activities listed in Figure 6-4 

(p. 172) establishes the TC community. 

Although each intervention has specific individual functions, all share community, therapeutic, and educational purposes. 

Key modifications 

The MTC alters the traditional TC approach in 

response to the client’s psychiatric symptoms, 

cognitive impairments, reduced level of functioning, short attention span, and poor urge 

control. A noteworthy alteration is the change 

from encounter group to conflict resolution 

group. Conflict resolution groups have the following features: 

• They are staff led and guided throughout. 

• They have three highly structured and often 

formalized phases—(1) feedback on behavior 

from one participant to another, (2) opportunity for both participants to explain their 

position, and (3) resolution between participants with plans for behavior change. 

• There is substantially reduced emotional 

intensity and an emphasis on instruction and 

the learning of new behaviors. 

Traditional Settings and Models 171 
Figure 6-4 

Residential Interventions 

Community Enhancement 

Morning Meeting Increases motivation for the day’s activities and creates a positive family 

atmosphere. 

Concept Seminars Review the concept of the day. 

General Interest Seminars Provide information in areas of general interest (e.g., current events). 

Program-Related Seminars Address issues of particular relevance (e.g., homelessness, HIV prevention, and psychotropic medication). 

Orientation Seminars Orient new members and introduce all new activities. 

Evening Meetings Review house business for the day, outline plans for the next day, and 

monitor the emotional tone of the house. 

General Meetings Provide public review of critical events. 

Therapeutic/Educative 

Individual Counseling Incorporates both traditional mental health and unique M TC goals and 

methods. 

Psychoeducational Classes Are predominant, using a format to facilitate learning among clients with 

COD; address topics such as entitlements/money management, positive 

relationship skills training, triple trouble group, and feelings management. 

Conflict Resolution Groups Modified encounter groups designed specifically for clients with COD. 

Medication/Medication Monitoring Begins with mental health assessment and medication prescription; continues with psychoeducation classes concerning the use and value of medication; and then monitors, using counselor observation, the peer community, and group reporting for medication adherence, side effects, and 

effectiveness. (See chapter 1, subsection titled “Pharmacological 

advances,” and chapter 5, subsection titled “Monitor Psychiatric 

Symptoms” for more details on the role of the counselor and the peercommunity in monitoring mental disorder symptoms and medication.) 

Gender-Specific Groups Combine features of “rap groups” and therapy groups focusing on gender-based issues. 

172 Traditional Settings and Models 
Figure 6-4 (continued) 

Residential Interventions 

Source: Sacks et al. 1999. 

Community and Clinical 

Management Policies 

A system of rules and regulations to maintain the physical and psychological safety of the environment, ensuring that resident life is orderly and 

productive, strengthening the community as a context for social learning. 

Social Learning Consequence A set of required behaviors prescribed as a response to unacceptable 

behavior, designed to enhance individual and community learning by 

transforming negative events into learning opportunities. 

Vocational 

Peer Work Hierarchy A rotating assignment of residents to jobs necessary to the day-to-day 

functioning of the facility, serving to diversify and develop clients’ work 

skills and experience. 

World of Work A psychoeducational class providing instruction in applications and interviews, time and attendance, relationships with others at work, employers’ 

expectations, discipline, promotion, etc. 

Recovery and World of Work A psychoeducational class that addresses issues of mental disorders, substance abuse, and so on, in a work context. 

Peer Advocate Training A program for suitable clients offering role model, group facilitator, and 

individual counseling training. 

Work Performance Evaluation Provides regular, systematic feedback on work performance. 

Job Selection and Placement Individual counseling after 6 months to establish direction and to determine future employment. 

•There is a persuasive appeal for personal 

honesty, truthfulness in dealing with others, 

and responsible behavior to self and others. 

In general, to create the MTC program for 


clients with COD, three fundamental alter­


ations were applied within the TC structure: 


• 

• 

• 

Increased flexibility 


Decreased intensity 


Greater individualization 


Nevertheless, the central TC feature remains; 


the MTC, like all TC programs, seeks to devel­


op a culture in which clients learn through 


mutual self-help and affiliation with the com­


munity to foster change in themselves and others. Respect for ethnic, racial, and gender differences is a basic tenet of all TC programs and 

is part of teaching the general lesson of respect 

for self and others. 

Figure 6-5 (p. 174) summarizes the key modifications necessary to address the unique needs 

of clients with COD. 

Role of the family 

While many MTC clients come from highly 

impaired and disrupted family situations and 

find in the MTC program a new reference and 

support group, some clients do have available 

Traditional Settings and Models 173 
Figure 6-5 

TC Modifications for Persons With COD 

Source: Sacks et al. 1999. 

Modifications to Structure Modifications to Process Modifications to Elements 

(Interventions) 

There is increased flexibility in program activities. Sanctions are fewer with greater 

opportunity for corrective 

learning experiences. 

Orientation and instruction are 

emphasized in programming and 

planning. 

Meetings and activities are shorter. Individual counseling is provided 

more frequently to enable clients to 

absorb the TC experience. 

There is greatly reduced intensity of 

interpersonal interaction. 

Engagement and stabilization 

receive more time and effort. 

Task assignments are individualized. 

More explicit affirmation is given 

for achievements. 

Breaks are offered frequently during work tasks. 

Greater sensitivity is shown to individual differences. Progression through the program is paced individually, 

according to the client’s rate of 

learning. 

Individual counseling and instruction are more immediately provided 

in work-related activities. 

There is greater responsiveness to 

the special developmental needs of 

the individual. 

Engagement is emphasized throughout treatment. 

More staff guidance is given in the 

implementation of activities; many 

activities remain staff assisted for a 

considerable period of time. 

Criteria for moving to the next 

phase are flexible to allow 

lower-functioning clients to 

move through the program 

phase system. 

Activities are designed to overlap. 

There is greater staff responsibility 

to act as role models and guides. 

Activities proceed at a slower pace. 

Smaller units of information are 

presented gradually and are fully 

discussed. 

Live-out re-entry (continuing 

care) is an essential component 

of the treatment process. 

Individual counseling is used to 

assist in the effective use of the community. 

Greater emphasis is placed on 

assisting individuals. 

The conflict resolution group 

replaces the encounter group. 

Increased emphasis is placed on 

providing instruction, practice, and 

assistance. 

Clients can return to earlier 

phases to solidify gains as necessary. 

174 Traditional Settings and Models 
intact families or family members who can be 

highly supportive. In those cases, MTC programs offer a variety of family-centered activities that include special family weekend visiting, family education and counseling sessions, 

and, where children are involved, classes 

focused on prevention. All these activities are 

designed in the latter part of treatment to facilitate the client’s reintegration into the family 

and to mainstream living. 

Empirical evidence 

A series of studies has established that 

•Homeless persons with COD have multiple 

impairments requiring multifaceted treatment (Sacks et al. 1997b, 1998a), and the 

homeless population with COD contains distinctive subgroups (De Leon et al. 1999). 

•Residential MTCs for people with COD, 

including women, produce significantly 

greater positive outcomes for substance use 

and employment than treatment as customarily provided (De Leon et al. 2000c). A 

parallel study (Rahav et al. 1995) also 

demonstrated significantly improved psychological functioning (e.g., lower depression) for an MTC group as 

compared to a “low demand” 

community residence program. 

•Preliminary evidence shows 

that TC-oriented supported 

housing stabilizes the gains 

from the residential program 

(Sacks et al. 2003a). 

•The cost of providing effective 

treatment through the MTC is 

no more than the cost of providing less effective treatment 

delivered through customarily 

available services (French et 

al. 1999; McGeary et al. 

2000). 

•MTC treatment produces $6 in 

benefit for every dollar spent 

(French et al. 2002). 

•Initial evidence indicates that 

those with both a mental and 

substance use disorder in an 

MTC group show significantly lower reincarceration rates than a group receiving 

regular mental health services (Sacks et al. 

2004). 

Current applications 

The MTC model has been adopted successfully 

in community residence programs for serious 

and persistent mental illness (Sacks et al. 

1998a), general hospitals (Galanter et al. 1993), 

and substance abuse treatment programs, both 

nationally (Caroll 1990) and internationally. It 

has spread particularly within TC agencies 

such as Phoenix House, Walden House 

(Guydish et al. 1994), Odyssey House, 

Gaudenzia, and Second Genesis. 

Manuals have been developed that describe the 

MTC programs (Sacks et al. 1998b, 2002) and 

principles of implementation (Sacks et al. 

1999). In addition, there are procedures that 

ensure the quality control of new applications 

(see section on “Continuous Quality 

Improvement” above). This information is useful to providers planning to develop MTC programs. A representative example of such MTC 

programs from Gaudenzia is provided on pages 

176–178. 

Advice to Administrators: 

Recommended Treatment and Services 

From the MTC Model 

In addition to all the guidelines for treatment cited in 

chapter 1, the following treatment recommendations 

are derived from MTC work and are applicable across all 

models. 

• Treat the whole person. 

• Provide a highly structured daily regimen. 

• Use peers to help one another. 

• Rely on a network or community for both support and 

healing. 

• Regard all interactions as opportunities for change. 

• Foster positive growth and development. 

• Promote change in behavior, attitudes, values, and 

lifestyle. 

• Teach, honor, and respect cultural values, beliefs, and 

differences. 

Traditional Settings and Models 175 
Gaudenzia, Inc., Pennsylvania 

Overview 

Gaudenzia, Inc. is a substance abuse treatment organization that provides a range of services at a number of different facilities. It is the largest nonprofit provider of substance abuse treatment services in the State of 

Pennsylvania, and it has more than 30 different facilities located across the State. Most programs are based on 

TC or MTC principles and methods. The entire agency has about 550 staff consisting of administrative management, clinical management, front line clinical, administrative, operational support, and nursing personnel. Most 

of the funding for these programs comes from municipal and State Offices of Mental Health. 

While Gaudenzia has facilities in a variety of different areas (urban, suburban, rural), all of the programs 

described below are in urban areas. Urban locations can support more specialized programs because they serve 

a larger population, with substantial concentrations of particular subgroups. Six of its facilities were developed 

as MTC programs to exclusively or primarily serve clients with COD, and a seventh has become a facility for 

people with HIV/AIDS and COD. They share a common perspective, principles, and methods, which are 

described below. 

Gaudenzia House Broad Street 

Gaudenzia House Broad Street is a 30-bed residential treatment program for adult men and women, 18 years or 

older, who have been diagnosed with both substance use disorders and co-occurring chronic and persistent mental disorders. This facility was opened as a response to the closure of Byberry, Philadelphia’s State Hospital, to 

provide community-based treatment for people with COD. Broad Street is a drug and alcohol and mental health 

residential program dually licensed by the Commonwealth of Pennsylvania Bureau of Drug and Alcohol 

Programs as a residential treatment program and by the Office of Mental Health as a residential treatment facility. The program also is accredited by the Joint Commission on Accreditation of Healthcare Organizations. The 

program uses an MTC approach to treat substance abuse, provides onsite mental health services for co-occurring mental disorders, and integrates substance abuse treatment and mental health services. Program services 

include individual counseling, work therapy, life skills training, group therapy, educational seminars on substance abuse and mental health, 12-Step and Double Trouble meetings, family counseling, and mental health 

treatment. 

Focus House 

Focus House is a long-term (9 months to 2 years) residential substance abuse treatment and mental health services program for men ages 18 and over who have chronic COD. This 12-bed facility provides substance abuse 

counseling, community residential rehabilitation, and transitional living arrangements for clients with severe and 

persistent mental illness. Focus House teaches clients the essential life skills they will need to live independent 

and productive lives in the community, to cease the substance abuse that complicates their mental illness, and to 

promote self-motivated involvement in the mental health service system. This program is used as a step-down 

from a more intensive residential inpatient program. All of the clients attend day programs at the local mental 

health center. In-house program services include group therapy, relapse prevention, individual counseling, 

socialization skill training, and life skills training. 

New Beginnings 

Gaudenzia’s New Beginnings is an 18-bed residential program that provides long-term residential care for 

homeless men and women who are chronically mentally ill and have co-occurring substance use disorders. 

The program initially is a “low-demand” environment that first addresses essential needs and then helps residents change the dysfunctional patterns that contribute to chronic homelessness and aggravate their mental 

disorders. It is called a “progressive demand facility,” which recognizes the need to meet clients where they 

are, but expects individuals to reach their potential through layering services and expectations in a logical 

building block manner. 

176 Traditional Settings and Models 
Joy of Living 

Gaudenzia’s Joy of Living is a 14-bed program that provides long-term (9 to 18 months) residential services for 

homeless men and women who have COD. The facility provides residents with shelter, support for recovery from 

substance abuse, and assistance in stabilizing the symptoms of chronic mental disorders. Clients at both the Joy 

of Living and New Beginnings programs (see above) arrive typically from a hospital or through interventions by 

city outreach workers or as a next step residence for those who have completed longer-term treatment but are not 

able to sustain themselves. They generally are not motivated for treatment and have many pressing needs that 

must be met before they are capable of engaging in a treatment program. Mental health treatment services are 

not provided onsite because the majority of the clients are in partial-hospital day programs off-site. Case management services are provided to help coordinate services based on clients’ abilities to engage in these services. 

The facility is considered a specialized progressive demand residence that engages people into formal treatment 

services by intervention and referral to outside services as needed, such as mental health care, medical services, 

and vocational/educational programs. Onsite substance abuse treatment includes individual and group counseling, treatment planning, life skills training, medication management, and 12-Step programs. 

Progress House 

Gaudenzia’s Progress House is a 14-bed moderate care community residential rehabilitation program for clients 

with COD. The facility has six apartments; one is an office and the other five are residences shared by the clients. 

The program provides semi-independent living for clients who have completed treatment at one of Gaudenzia’s 

other programs. Staff is onsite 16 hours a day, and residents are provided with counseling for mental health and 

substance abuse issues. All clients go to mental health service programs, vocational programs, or sheltered workshops during the day. Program services include life skills training, vocational guidance, 12-Step meetings, and 

transitional living services. 

New View 

Gaudenzia’s New View was established to provide community residential rehabilitation services to adult residents 

(both men and women) of Dauphin County who have SMI and a history of drug and alcohol problems. The program can last up to 2 years depending on a client’s clinical progress. The eight-bed program has the features of 

an MTC, with a strong emphasis on community reintegration. The goal for the majority of the clients is to obtain 

employment in the community during the later stages of treatment. There also is a strong family component and a 

weekly continuing care group for clients who have completed inpatient care and are making the transition to 

independent living. 

People With Hope 

This program is an MTC 23-bed facility for adult men and women who have AIDS (and are symptomatic) with a 

variable length of treatment (3 to 9 months); the majority of these clients have co-occurring substance abuse and 

mental disorders. The goal is to provide substance abuse treatment, shelter, medical care, seminars on HIV disease, and educational services that are designed to enhance the quality of life for the individual. The services during the intensive phase of treatment include individual and group therapy, work therapy, GED/literacy classes, 

and daily seminars that focus on life skills, AIDS-related issues, parenting, sexual orientation, nutrition, relapse 

prevention, budgeting, and socialization. The re-entry and continuing care phases of the program include a transitional living component and a strong emphasis on 12-Step participation. For those clients who have a co-occurring disorder, ongoing mental health services such as medication evaluation and monitoring are arranged through 

the nearby community mental health center. People With Hope has a nursing staff onsite providing medication 

management and health care case management. 

Together House 

Together House consists of three distinct programs in the same building licensed by the Commonwealth of 

Pennsylvania under one umbrella to provide residential treatment for three distinct populations. Among the 

three tracks, a total of 57 clients are served. The three programs are (1) Men’s Forensic Intensive Recovery proTraditional Settings and Models 177 
gram (MFIR), (2) Women’s Forensic Intensive Recovery program (WFIR), and (3) Short-Term Program (STP). 

MFIR and WFIR each provide residential treatment for 24 adults with COD who have been referred through 

the City of Philadelphia Forensic network. The majority of these clients come directly to Together House from 

the city prison system where they have been incarcerated for drug- or alcohol-related offenses. 

This program represents a major effort by the city of Philadelphia to provide treatment instead of incarceration 

to individuals with substance use disorders, recognizing the special needs of the person with COD. The STP 

serves nine men and women who have HIV, are homeless, and have COD. They must have issues of addiction 

and also have a co-existing mental disorder. The purpose of STP is engagement, stabilization, thorough assessment, and referral for longer-term treatment. Maximum length of stay is 4 to 6 weeks. In each track, all services 

are provided onsite, including a full nursing staff, medical management, mental health services, individual and 

group counseling, life skills education, health and mental health education, vocational planning, onsite 12-Step 

meetings, and recreational programming. 

FIRst Program 

The Department of Corrections FIRst (Forensic Intensive Recovery state) is located in the Together House complex and provides a community corrections transitional living program for men coming from incarceration in the 

State penal system with SMI and substance abuse issues. Started in the summer of 1999, this program was a 

response to a gaping lack of support for men who were returning to their communities after serving lengthy sentences for what was often a drug- or alcohol-related offense. Their SMI presented a particular problem for early 

release, hence the FIRst program was indeed a first effort to aid in transition from incarceration to community 

living. 

There are 24 men in residence for 9 to 12 months, with a thorough initial evaluation and stabilization period, 

followed by increasing reliance on services in the community, decreasing dependence on the program, and gradual re-introduction to the world of work, if possible. Onsite counseling (group and individual), nursing support, 

mental health services, vocational assessment and referral, recreation, and resocialization classes are all provided. However, after initial engagement, community services are utilized to aid in practicing accessing outside supports in planning a return to outside life. 12-Step meetings are provided onsite and through outside groups. 

Recommendations 

A considerable research base exists for the 

MTC approach, and the consensus panel recommends the MTC as an effective model for 

treating persons with COD, including those 

with SMI. Recently, the MTC has been rated as 

one of a few promising practices for COD by 

the National Registry of Effective Programs 

and Practices (NREPP), as part of NREPP’s 

ongoing evaluation of COD strategies and models. However, although improved psychological 

functioning has been reported, differential 

improvement in mental health functioning 

using the MTC approach in comparison to 

more standard treatment has yet to be demonstrated. The TC and MTC approach, although 

demonstrably effective with various populations of people who use drugs, including those 

with COD, encounters difficulty in achieving 

more widespread acceptance. To accomplish 

greater receptivity to TC and application of its 

methods, several developments are necessary: 

• The principles, methods, and empirical data 

on MTC approaches need better articulation 

and broader dissemination to the mental 

health and other treatment fields. The development of MTCs in mainstream mental 

health programs is one useful approach 

(Galanter et al. 1993). 

• The application of MTC methods for COD in 

non-TC medical and mental health settings 

needs to be established more firmly. It is 

especially important to ascertain whether, 

and to what extent, these methods can be 

separated from their TC framework and 

made “portable” as services to be used by 

other systems and approaches. 

• As MTC programs continue to adapt for specific populations (e.g., adolescents, prison 

178 Traditional Settings and Models 
inmates, people with COD, women and children), their longer term effectiveness after 

treatment needs to be evaluated. 

•Quality assurance of MTC programs is essential. The theory-based work of De Leon and 

his colleagues for standard TCs provides the 

necessary tools for this effort. Specifically, 

the development of an instrument for measuring the essential elements of TC programs 

(Melnick and De Leon 1999) and the development of standards for TC prison programs 

(with Therapeutic Communities of America 

1999) enable the service and research communities to assess to what extent TC programs contain the essential elements and 

meet applicable standards. Further work is 

needed in adapting these instruments for 

MTC programs. 

Additional Residential Models 

A variety of other residential models have been 

adapted for COD. Two representative models 

are the Na’nizhoozi model in the Southwest, 

designed for American Indians with alcohol 

problems, with the recent incorporation of services for COD (p. 180); and the Foundations 

Associates model that integrates short-term residential treatment with outpatient services (pp. 

181–182). 

Traditional Settings and Models 179 
The Na’nizhoozi Center, Inc. (NCI) 

Overview 

The NCI has facilities in the town of Gallup, New Mexico (population 20,000), and serves clients throughout a 

largely rural region of some 450,000 square miles, spanning two States and multiple counties within those States. 

(In fact, because of the unique nature of the services it offers, the program has accepted clients from across the 

United States.) The population in the area served by the program predominantly is American Indian. 

In 1992, the Navajo Nation, the City of Gallup, the Zuni Pueblo, and McKinley County created NCI to address 

a significant public intoxication problem in Gallup and in McKinley County, New Mexico. In the 1980s, Gallup 

alone had more than 34,000 people placed into protective custody for public drunkenness; in 1999, this number 

had decreased to 14,600. 

Clients 

The client population is 95 percent American Indian with the great majority (approximately 93 percent) being 

members of the Navajo Nation. The program has a 150-bed residential facility built to provide service primarily 

to clients in protective custody (a form of criminal justice sanction that does not involve felony or misdemeanor 

or other criminal charge in a minimum-security setting, meaning that all doors are locked and the units are segregated). 

The primary substance abused by clients entering NCI is alcohol, and the majority of clients (70 percent) is 

male. Clients exhibit an array of psychological problems and mental disorders. The incidence of COD with the 

protective custody population is 20 percent. Posttraumatic stress disorder, major affective disorders, and personality disorders are seen most commonly at NCI. 

NCI also has a 3-week short-term residential program that is based on American-Indian philosophy. The NCI 

averages 12 clients per day, of whom 25 percent are admitted from the protective custody residential unit. 

Services 

NCI’s 28-day residential program consists of 150 beds and provides services that are based largely on practices 

from both Dine’ (Navajo) and intertribal traditions. Treatment literature emphasizes culturally appropriate 

interventions and NCI has made a major effort toward accomplishing this with the American-Indian population 

it serves. Sweat lodge ceremonies, Talking Circles, language, appropriate individual and group counseling, and 

culture-based treatment curricula are a few of the initiatives used. Sweat lodge ceremonies are nondenominational group activities with a strong spiritual component. Participants discuss problems or successes in life and 

receive feedback from other participants. Talking Circles often have a greater number of participants than the 

sweat lodge ceremonies with less interaction between the speaker and others in the circle. An important factor 

associated with both activities is that they often are conducted in the native language with Navajo values emphasized in the dialog. Because more than one tribe is served at NCI, the services are designed to meet the needs of 

different tribal cultures in the southwestern region. 

The program has been increasing its services for clients with COD, which include referral to psychiatric assessment, medication, and case management. NCI provides residential and shelter services to support psychiatric 

interventions by monitoring medication use and providing crisis intervention services within the context of the 

facility. 

180 Traditional Settings and Models 
Foundations Associates 

Foundations Associates in Nashville, Tennessee offers a residential program and a fully integrated continuum of 

care for clients with COD. Foundations’ residential model employs a TC-like structure modified to incorporate 

best practice concepts for COD. Foundations’ program has been recognized as a national leader in serving 

clients with co-occurring substance abuse and SMI, such as schizophrenia. 

Clients 

Foundations typically serves clients diagnosed with substance dependence and SMI. Approximately 70 percent 

of Foundations’ residents are diagnosed with schizophrenia, schizo-affective, or mood disorders with psychotic 

features. Typical substance abuse problems include crack/cocaine, alcohol, and cannabis. Fifty percent of 

Foundations’ consumers are women, and 80 percent are referred from primary substance abuse or mental 

health treatment programs, typically after referring staff recognize the presence of a second (co-occurring) disorder. 

Assessment 

Substance abuse, mental health, physical health, vocational/educational, financial, housing/life skills, spiritual, 

and recreational/social needs are assessed prior to program enrollment. Individualized therapy and case management plans are developed and service matching is determined through the assessment (using ASAM Patient 

Placement Criteria, Second Edition, Revised). Based on the assessment, clients are assigned to appropriate services. 

Services 

Core residential services include Dual Diagnosis Enhanced Therapeutic Community, Halfway House, and 

Independent Living levels of care. Clients progress through the residential program in a series of five stages, 

based on clinical progress and earned privilege. All clinical activities, including treatment team staffing, are fully 

integrated to blend treatment for substance use and mental disorders. Program services are comprehensive to 

meet the complex needs of clients, and frequently include case management, vocational rehabilitation, individual/family/group therapy, and skills training. 

Evaluation 

Initial findings from a 3-year CSAT-funded evaluation of Foundations’ residential program indicated abstinence 

in 70 to 80 percent of Foundations’ clients up to 1 year following treatment. Severity of psychiatric symptoms 

was reduced by 60 percent, with corresponding improvements in quality of life. Perhaps most notably, high-cost 

service utilization dropped substantially following integrated treatment, with 80 to 90 percent reductions in 

inpatient and emergency room (ER) visits related to substance use or mental health problems. Likewise, inpatient and ER visits for general health care declined by 50 to 60 percent. Service profiles showed an increase in 

appropriate, cost-effective utilization of community supports and services. These results suggest that the program model of integrated and continuous treatment breaks the repetitive cycle of traditional substance abuse 

and mental health treatment for consumers with COD. 

Best Practices 

Best practice integrated treatment concepts serve as the basis for all program activities, including 

• Continuous cross-training of professional and nonprofessional staff 

• Empowerment of clients to engage fully in their own treatment 

• Reliance upon motivational enhancement concepts 

• Culturally appropriate services 

• A long-term, stagewise perspective addressing all phases of recovery and relapse 

• Strong therapeutic alliance to facilitate initial engagement and retention 

Traditional Settings and Models 181 
Foundations Associates (continued) 

•Group-based interventions as a forum for peer support, psychoeducation, and mutual self-help activities 

•A side-by-side approach to life skills training, education, and support 

•Community-based services to attend to clinical, housing, social, or other needs 

•Fundamental optimism regarding “hope in recovery” by all staff 

These principles reflect best practice concepts for COD, but the challenge lies in day-to-day program implementation. To facilitate broader adoption of integrated practices, Foundations Associates will make available upon 

request implementation guides, program manuals, and clinical curricula for programs interested in adapting this 

model to their community. 

Contact information, detailed program materials, and research findings may be obtained via Foundations’ Web 

site at http://www.dualdiagnosis.org. 

182 Traditional Settings and Models 
7 Special Settings and 

Specific Populations 

In This 

Chapter... 

Acute Care and



Other Medical



Settings



Dual Recovery



Mutual Self-Help



Programs



Specific



Populations



Overview 

Building on the programmatic perspective of chapter 6, this chapter 

describes substance abuse treatment for co-occurring disorders (COD) 

within special settings and with specific populations. The chapter begins 

with a discussion of treatment in acute care and other medical settings. 

While not devoted to drug treatment, important substance abuse treatment does occur there, hence their inclusion in the TIP. Two examples of 

medical settings in which care is provided for clients with COD are presented: the Harborview Medical Center of Seattle, Washington, a teaching and research county hospital that serves a number of clients with 

serious mental illness (SMI) and severe substance abuse; and the HIV 

Integration Project (HIP), run out of The CORE Center, an ambulatory 

infectious disease clinic in Chicago, Illinois. HIP provides integrated 

care to persons living with HIV/AIDS who also are diagnosed with cooccurring mental and substance use disorders. 

This chapter then turns to a description of the emerging dual recovery 

mutual self-help programs, and the work of various advocacy groups 

is highlighted. Finally, specific populations of clients with COD are 

discussed, including the homeless, women, and those in criminal justice settings. This section highlights the treatment strategies that have 

proven effective in responding to the needs of these populations. 

Several examples of programs designed to serve such populations are 

cited, including a variety of models for trauma. Two such programs 

for specific populations are illustrated: the Clackamas County programs (Oregon City, Oregon) for persons with COD who are under 

electronic surveillance or in jail and the Triad Women’s Project, 

located in a semi-rural area of Florida that spans three counties. The 

latter program was designed to provide integrated services for women 

with histories of trauma and abuse who have COD. 

Additionally, this chapter contains Advice to the Counselor boxes, to 

provide readers who have basic backgrounds with the most immediate 

practical guidance. (For a full listing of these boxes see the table of 

contents.) 

183 
Acute Care and Other 

Medical Settings 

Background 

Although not substance abuse treatment settings per se, acute care and other medical settings are included here because important 

substance abuse and mental health treatment 

do occur in medical units. Acute care refers 

to short-term care provided in intensive care 

units, brief hospital stays, and emergency 

rooms (ERs). Providers in acute care settings 

usually are not concerned with treating substance use disorders beyond detoxification, 

stabilization, and/or referral. In other medical settings, such as primary care offices, 

providers generally lack the resources to provide any kind of extensive substance abuse 

treatment, but may be able to provide brief 

interventions (for more information see TIP 

24, A Guide to Substance Abuse Services for 

Primary Care Clinicians [Center for 

Substance Abuse Treatment (CSAT) 1997a]). 

Exceptions are programs for chronic physical 

illnesses such as HIV/AIDS, which may have 

the staff and resources to provide some types 

of ongoing treatment for mental illness and/or 

substance abuse. TIP 37, Substance Abuse 

Treatment for Persons With HIV/AIDS 

(CSAT 2000e), provides comprehensive information on substance abuse treatment for this 

population, including integrated treatment 

for people who have substance use disorders 

and HIV/AIDS as well as co-occurring mental 

disorders. 

The integration of substance abuse treatment 

with primary medical care can be effective in 

reducing both medical problems and levels of 

substance abuse. More clients can be engaged 

and retained in substance abuse treatment if 

that treatment is integrated with medical care 

than if clients are referred to a separate substance abuse treatment program (Willenbring 

and Olson 1999). While extensive treatment 

for substance abuse and co-occurring mental 

disorders may not be available in acute care 

settings given the constraints on time and 

resources, brief assessments, referrals, and 

interventions can be effective in moving a 

client to the next level of treatment. 

More information on particular issues relating to substance abuse screening and treatment in acute and medical care settings can 

be found in TIP 16, Alcohol and Other Drug 

Screening of Hospitalized Trauma Patients 

(CSAT 1995a); TIP 19, Detoxification From 

Alcohol and Other Drugs (CSAT 1995c); and 

TIP 24 (CSAT 1997a). More information on 

the use and value of brief interventions can 

be found in TIP 34, Brief Interventions and 

Brief Therapies for Substance Abuse (CSAT 

1999a). 

Examples of Programs 

Because acute care and primary care clinics 

are seeing chronic physical diseases in combination with substance abuse and psychological illness (Wells et al. 1989b), treatment 

models appropriate to medical settings are 

emerging. Two programs, the Harborview 

Medical Center’s Crisis Triage Unit (CTU) in 

Seattle and The CORE Center (an ambulatory facility for the prevention, care, and 

research of infectious disease) in Chicago, are 

examples of two different medical settings in 

which COD treatment has been effectively 

integrated. (For a full description of these 

programs, see the text boxes on pages 185 and 

186.) The consensus panel notes that the programs selected have advantages over more 

typical situations—the Harborview Medical 

Setting is a teaching and research hospital 

run by the county and The CORE Center has 

the support of a research grant. Nonetheless, 

program features are suggestive of the range 

of services that can be offered. 

The programs featured above typify the “no 

wrong door” to treatment approach (CSAT 

2000a). These providers have the capacity to 

meet and respond to the client at the location 

where care is requested, ensuring that each disorder is addressed in the treatment plan. 

184 Special Settings and Specific Populations 
Harborview Medical Center’s Crisis Triage Unit, 

Seattle, Washington 

Overview 

The Harborview Medical Center is a teaching and research county hospital owned by King County and managed by the University of Washington. As the major trauma center facility in the Seattle area, it receives clients 

from throughout the Pacific Northwest. The Center has by far the busiest ER in the region, part of which is 

dedicated to the Crisis Triage Unit for clients with substance abuse and/or mental illness–related emergencies. 

Across the street from the program is a walk-in crisis center for persons with less severe psychological or substance-related disorders and drug-related emergencies. 

Clients Served 

The type of clients seen differs at each of the Center’s locations. Although clients representative of each of the 

four quadrants are served, those seen in the ER fall generally into quadrant IV of the four-quadrant model, 

that is, those with SMI and severe substance abuse problems (see chapters 2, 3, and 4 for more information 

about the four-quadrant system). 

Services 

The focus of services at the CTU is on acute care. Primary goals are to ensure safety, assessment, stabilization, 

and, as needed, triage to another level of care (either within the facility or outside). The CTU’s treatment can 

involve intensive medical interventions (which may mean that the client is sent back to the medical/surgical ER), 

psychiatric interventions (which may include engagement, assessment, acute medications, and even use of 

restraints), substance abuse–related interventions (emergency detoxification, treatment for withdrawal, and 

HIV screening and counseling), and holding and referral activities. Clients’ needs vary greatly; while some may 

only receive a brief crisis intervention, others will require medical care and medication, and still others need 

social services such as referral to housing. 

The Crisis Triage Unit has a 23-hour holding area in the ER where clients can be held long enough to be evaluated (the average length of stay is 4.5 hours). About 1,000 clients come through the CTU each month and close 

to half of these have co-occurring substance use and mental disorders. Based on the client’s needs, disposition 

can range from brief evaluation and referral to involuntary acute inpatient hospitalization. 

Over the years, staff providing integrated treatment for people with COD have been placed (1) in the CTU, (2) 

on all three inpatient acute psychiatric units, (3) in the mental health center outpatient program, (4) at the offsite substance abuse treatment detoxification unit, and (5) at the regional substance abuse treatment residential 

center. Most of the larger mental health centers in the area have developed treatment tracks for persons with 

COD, and several of the larger substance abuse treatment agencies have hired onsite, part-time psychiatrists. 

Providing Treatment to Clients 

With COD in Acute Care and 

Other Medical Settings 

Programs that rely on identification (i.e., 

screening and assessment) and referral have a 

particular service niche within the treatment 

system; to be successful, they must have a clear 

view of their treatment goals and limitations. 

Effective linkages with various communitybased substance abuse treatment facilities are 

essential to ensure an appropriate response to 

client needs and to facilitate access to additional services when clients are ready. This section 

highlights the essential features of providing 

treatment to clients with COD in acute care 

and other medical settings. 

Special Settings and Specific Populations 185 
The HIV Integration Project of The CORE Center, 

Chicago, Illinois 

Overview 

The HIV Integration Project (HIP) is run out of The CORE Center, an ambulatory infectious disease clinic in 

Chicago, Illinois. It is part of a cooperative agreement funded by six Federal agencies. The goal of this project is 

to evaluate the impact of the integration of primary care, mental health, and substance abuse treatment services 

on the healthcare costs, treatment adherence, and health outcomes of persons living with HIV/AIDS who also 

are diagnosed with co-occurring mental health and substance use disorders. 

Clients Served 

The center serves more than 3,000 HIV-infected clients annually. Clients predominantly are economically disadvantaged minorities, and include 33 percent women, 73 percent African Americans, 14 percent 

Hispanics/Latinos, and 12 percent Caucasians. Approximately one-third of the clients present with co-occurring 

mental health and substance use disorders. 

Services 

Many settings, despite close proximity, may deliver “co-located” care but not fully integrated care. The HIP 

model focuses on developing a behavioral science triad that consists of a mental health counselor, a substance 

abuse treatment counselor, and a case manager. Both medical and social service providers are present during 

outpatient HIV clinic sessions and clients are screened for eligibility onsite. The triad works together to assess, 

engage, and facilitate clinically appropriate services for clients with HIV and COD. If clients need immediate 

services—such as housing, psychiatric hospitalization, or detoxification—the appropriate triad member will 

facilitate linkage and coordination of care. Outpatient mental health care and substance abuse treatment are 

offered at the same center where clients receive their primary care. 

The triads meet jointly with their clients. They develop joint assessments and treatment plans, communicating 

regularly with medical providers. Emphasis is placed on facilitating six processes among mental health, chemical 

dependency, case management, and medical providers: (1) interdisciplinary team identity building, (2) coordination and communication, (3) cross-disciplinary learning, (4) outreach for clients who do not engage initially or 

sustain mental health or substance abuse care, (5) mental health services, and (6) specialized training in the 

care of triply diagnosed clients. 

Screening and assessment 

(in acute and other medical 

settings) 

Clients entering acute care or other medical 

facilities generally are not seeking substance 

abuse treatment. Often, treatment providers 

(primary care and mental health) are not familiar with substance use disorders. Their lack of 

expertise can lead to unrealistic expectations or 

frustrations, which may be directed inappropriately toward the client. 

The CORE Center serves as a good example 

of effective screening and assessment. To 

facilitate early identification of substance 

abuse and mental disorders within the HIV 

client population, The CORE Center attempts 

routine screening of all new clients accessing 

primary care. Treatment begins at the screening or assessment phase; the triad assesses not 

only psychological functioning and substance 

abuse severity, but also readiness for change. 

The provider will offer only those services 

that the client is willing to accept. Examples 

include literature to educate the client on his 

disorders, case management to address housing or other needs, or referral for detoxification. Next, the triad tries to engage the client, 

creating a positive experience that encourages 

186 Special Settings and Specific Populations 
return visits. Since continuity of care is 

important, the triad attempts to follow clients 

while hospitalized and to work with inpatient 

medical staff in the same manner as with outpatient staff. 

A majority of clients do return to The CORE 

Center for their primary care treatment. 

Primary care providers keep the triad 

informed of client visits so that counselors 

can build a trusting working relationship with 

clients that facilitates engagement in mental 

health or substance abuse care. After meeting 

with clients, the triad briefs the medical 

providers on the clinical disposition and 

treatment strategy. Often, these briefing sessions serve as an opportunity for cross-disciplinary learning. The CORE Center frames 

its treatment philosophy as holistic, and in 

one setting treats both the physical and emotional problems the client is experiencing. 

At Harborview, clients are given a multidisciplinary evaluation that has medical, mental 

health, substance abuse, and social work 

components. Harborview does not employ 

any dedicated staff for performing evaluation, but rather trains a variety of staff to 

perform each part of the evaluation. Because 

of the nature of the setting (the fast-paced 

world of an emergency room), the basic 

assessments usually can be performed in 30 

minutes, but may take longer in more complicated cases (e.g., if a client cannot communicate because of a speech disorder and information can be gathered only from records or 

family). Chapter 4 contains a full description 

of screening and assessment procedures and 

instruments applicable to COD. 

Accessing services 

The CORE Clinic offers clinical interventions 

focused on crisis counseling, single session 

treatment, motivational enhancement, shortterm mental health services and substance 

abuse treatment counseling, and psychoeducation as appropriate while the client is in The 

CORE Center. Primary care providers sometimes are asked to help reinforce treatment recommendations and to join in being “one unified 

voice” that the client hears. 

Given the diversity among people with COD, 

treatment referrals from The CORE Center 

are varied, ranging from residential substance abuse treatment to acute psychiatric 

hospitalization; solid working relationships 

with treatment communities are needed 

across settings. When the client is ready for 

more intensive treatment, the triad provides a 

critical triage function to the larger substance 

abuse treatment and mental health services 

communities. 

When Harborview set up its CTU program, 

part of its contract required that the county 

mental health and substance abuse treatment 

systems provide “back door” staff with the 

authority to ensure client access to other 

required services. At least one of these staff is 

onsite 16 hours each day to make referrals 

for clients being discharged from the CTU. 

This service has proven extremely important 

for ensuring both that continuing care for 

COD is provided to clients leaving the unit 

and that disposition of CTU clients is efficient. 

Implementation 

Administrators who may be considering integrating substance abuse treatment and/or mental health services within existing medical settings should realize that they are introducing a 

new model of care. The systems and operating 

culture in place may view changes as unnecessary. Similar to the way in which providers 

assess a client’s readiness for change (i.e., 

readiness for treatment), administrators should 

assess organizational readiness for change 

prior to implementing a plan of integrated 

care. This assessment should consider space for 

additional staff, establish a clear organizational 

reporting structure, and allow time for 

providers to work in partnership with other 

disciplines. 

Special Settings and Specific Populations 187 
The assessment will inform the planning process. In developing a plan, administrators 

should: 

• Seek input from all stakeholders, especially 

the clients, a necessary prerequisite to developing or offering services. This information 

can be gathered through archival data, focus 

groups, and provider interviews. 

•Clarify the role of each of the primary care, 

substance abuse treatment, and mental 

health treatment providers. 

•Clearly specify the desired outcome(s) for 

mental health and substance abuse treatment 

services. 

•Outline and pilot both formal and informal 

communication mechanisms prior to full 

implementation of services. 

When developing and implanting the program, 

administrators should not minimize or ignore 

the fact that the medical and social service cultures are very different; opportunities must be 

provided for relationship and team building 

(ideally in informal settings). Finally, continued 

monitoring and flexibility in the development of 

the model are critical. 

Staffing, supervision, and 

training 

Cross-training/cross-disciplinary 

learning 

Cross-training of staff in acute care settings 

may be more difficult than in other settings 

because of the greater variety of staff present, 

but these activities are no less essential. For 

example, in the Harborview program, staff 

members include numerous doctors, nurses, 

physician assistants, psychiatric residents in 

training, medical students, social workers, 

social work students, substance abuse treatment counselors, and security officers. Such 

settings have a greater number of stakeholders than dedicated substance abuse treatment 

programs—all of whom will need to be 

involved, at some level, in the development 

and implementation of a program for clients 

with COD. Moreover, staff assigned to integrated settings will have varying degrees of 

commitment to integrated care. Staff also will 

come into these settings with different definitions of integrated care. They may have varying treatment approaches or may use discipline-specific language that inadvertently can 

become a barrier to integration. Time and 

other resource limitations can also pose an 

obstacle. The CORE Center’s medical care 

providers cite time constraints as a major 

impediment to close working relationships 

with social service staff. 

The CORE Center’s staff training program 

serves to illustrate the potential of crosstraining. Staff who work in The CORE 

Center have begun to look at cross-training 

more as cross-disciplinary learning. They are 

discovering what each discipline does, its language and beliefs, and the role of that discipline in the client’s treatment. For example, 

even though a substance abuse treatment 

counselor may never serve as a primary care 

provider, the counselor can appreciate how 

this provider contributes to the client’s wellbeing. Likewise, primary care providers can 

learn from case managers about the challenges of finding housing for clients with 

COD. Social service staff wear lab coats that 

identify their discipline and team affiliation 

during clinic sessions; this simple but noticeable change helps social service staff feel a 

sense of belonging and supports team-building 

efforts. Mutual respect for the disciplines and 

a deeper understanding of the interrelatedness of the various staff functions develop 

over time. 

Team building 

Staff training and consultation can help bring 

all staff on board and unify treatment 

approaches. To foster team building, The 

CORE Center has incorporated key components of competent care teams as discussed in 

the geriatric and oncology literature 

(Wadsworth and Fall Creek 1999). This effort 

includes formal and informal team building, 

training on working in an integrated healthcare 

team, and clear communication mechanisms. 

188 Special Settings and Specific Populations 
Effective integrated care teams take time to 

develop, and a number of institutional and disciplinary barriers make it difficult for staff 

from different areas of expertise to work 

together. For instance, differences in philosophies of treatment and traditions of care, as 

well as differences in how language is used to 

describe and discuss disorders, can lead to 

major communication problems. Thus, staff 

need opportunities to become familiar with the 

vocabulary of substance abuse treatment, mental health services, and medical treatment. 

Types of training 

Specific training needs will vary depending on 

the type of program, but some mechanism for 

cross-training activities in acute care settings 

needs to be in place. The CORE Center has 

found it useful to have formal training activities where an instructor is invited into the 

facility (which, in their experience, works 

better than sending staff out of the facility for 

training). This strategy may be used in combination with informal training mechanisms, 

such as providing feedback to medical staff 

concerning The CORE Center program so 

they can better understand how medical decisions affect clients’ success in substance abuse

treatment and mental health services. 

Continuing care and transition issues 

Since medical care is continuous for clients 

with chronic medical conditions, continuing 

care (also called aftercare) or transition 

issues can become blurred for both clients 

and providers. The CORE Center attempts to 

facilitate linkage to more intensive services, 

but realizes that chronically ill clients do not 

make status transitions in the traditional 

sense, but rather enter periods of stability 

when little intervention is required. Because 

episodic use of services by these clients is the 

norm, staff need to be flexible and to realize 

that these clients are likely to return to The 

CORE Center when in crisis. This reality 

underscores the requirement for strong linkages to other services for clients who need a 

more intensive level of care than is available 

in acute or outpatient care. 

Administrators 

who may be 

considering integrating substance abuse

treatment

and/or mental

health services 


within existing 


medical settings


should realize 

that they are

introducing a

new model of 

care. 

Program evaluation 

In developing programs such as the HIV 

Integration Project or Harborview, it is critical to incorporate program evaluation activities that examine 

both process and 

outcome. The evaluation of these programs can prove 

challenging. Logic 

models that 

describe the interrelationship between 

the conceptual 

framework, client 

demographics, 

treatment services, 

and expected outcomes are useful to 

guide evaluation 

efforts and to iden­


tify immediate, 


short-, and longterm outcomes. 


Evaluators should 

add measures such 


as increased treatment and medica­


tion adherence, 


quality of life, and 

physical health to 

the more standard 

outcome measures 

such as abstinence 

or remission of psychiatric symptoms. 

Since many of the 

gains involve 

improvement in 

quality of life and 

physical well-being, 

evaluations that incorporate quantitative and 

qualitative methods have the best success in 

capturing the impact of these integrated services. Given the high cost of medical care, 

Special Settings and Specific Populations 189 
economic analyses of the cost and benefits 

associated with treatment are essential. 

Sustaining Programs for 

Clients With COD in Acute 

Care Settings 

Acute care and other medical care settings 

generally will rely on very different funding 

streams than are available to outpatient or 

residential substance abuse treatment programs. These funding sources will vary 

depending on the type of program. At 

Harborview, for example, most funds come 

from the medical and mental health systems; 

very little substance abuse treatment money is 

involved. The program at Harborview has 

been highly visible and has a number of key 

county stakeholders (e.g., Department of 

Mental Health, Department of Alcohol and 

Drugs, County Hospital), which helps avoid 

budget cuts. Harborview also has clearly 

positioned itself as the program of last resort 

in the region and has developed its programs 

accordingly. Further, it has created a stateof-the-art integrated information system (each 

assessment generates a database entry); this 

enables staff to prepare detailed quality and 

clinical reports, which are of value to the 

entire system. 

Initial funding for The CORE Center came 

from the Substance Abuse and Mental Health 

Services Administration (SAMHSA) through 

the AIDS demonstration program of 

SAMHSA’s Center for Mental Health Services 

(CMHS). Additional funding was provided 

through other grants through CSAT. Funding 

from the Health Resources and Services 

Administration through the Ryan White Care 

Act supports opportunities to offer more 

intensive integrated services. Other funding 

mechanisms, such as private foundation 

grants, serve as vehicles to secure financial 

support for these unique integrated services. 

At present, it is difficult to secure sustained 

funding from sources such as Medicare or 

Medicaid. Continuing funding comes from the 

Ryan White Care Act with some additional 

funds from the county. 

Dual Recovery Mutual 

Self-Help Programs 

The dual recovery mutual self-help movement 

is emerging from two cultures: the 12-Step fellowship recovery movement and, more recently, the culture of the mental health consumer 

movement. This section describes both, as well 

as other, consumer-driven psychoeducational 

efforts. 

Background 

During the past decade, mutual self-help 

approaches have emerged for individuals 

affected by COD. Mutual self-help programs 

apply a broad spectrum of personal responsibility and peer support principles, usually 

including 12-Step methods that prescribe a 

planned regimen of change. These programs 

are gaining recognition as more meetings are 

being held in both agency and community settings throughout the United States, Canada, 

and abroad. 

In recent years, dual recovery mutual selfhelp organizations have emerged as a source 

of support for people in recovery from COD 

(DuPont 1994; Ryglewicz and Pepper 1996). 

Such groups sometimes have been described 

as special needs groups for people in recovery 

from substance use disorders (Hendrickson et 

al. 1996; White 1996). Mental health advocacy organizations—including the National 

Alliance for the Mentally Ill and the National 

Mental Health Association—have published 

articles that have identified dual recovery 

mutual self-help organizations (Goldfinger 

2000; Hamilton 2000). At the Federal level, 

SAMHSA also has produced documents identifying dual recovery mutual self-help organizations (CMHS 1998; CSAT 1994a). 

The new dual recovery mutual self-help organizations are important signs of progress in 

several respects: First, they encourage men 

and women who are affected by COD to take 

responsibility for their personal recovery. 

Second, they reflect a growing trend toward 

consumer empowerment (Hendrickson et al. 

190 Special Settings and Specific Populations 
1994). Finally, they reflect recognition of the 

importance of peer support in sustained 

recovery. 

Several issues serve as the rationale for establishing dual recovery programs as additions to 

previously existing 12-Step community groups. 

To paraphrase Hamilton’s review (Hamilton 

2001): 

•Stigma and Prejudice: Stigma related to 

both substance abuse and mental illness 

continues to be problematic, despite the 

efforts of many advocacy organizations. 

Unfortunately, these negative attitudes may 

surface within a meeting. When this occurs, 

people in dual recovery may find it difficult 

to maintain a level of trust and safety in the 

group setting. 

•Inappropriate Advice (Confused Bias): 

Many members of substance abuse recovery 

groups recognize the real problem of crossaddiction and are aware that people do use 

certain prescription medications as intoxicating drugs. Confusion about the appropriate role of psychiatric medication exists, 

and as a result, some members may offer 

well-intended, but inappropriate, advice by 

cautioning newcomers against using medications. Clearly, confused bias against medications may create either of two problems. 

First, newcomers may follow inappropriate 

advice and stop taking their medications, 

causing a recurrence of symptoms. Second, 

newcomers quickly may recognize confused 

bias against medications within a meeting, 

feel uncomfortable, and keep a significant 

aspect of their recovery a secret. 

•Direction for Recovery: A strength of traditional 12-Step fellowships is their ability to 

offer direction for recovery that is based on 

years of collective experience. The new dual 

recovery programs offer an opportunity to 

begin drawing on the experiences that members have encountered during both the progression of their COD and the process of 

their dual recovery. In turn, that body of 

experience can be shared with fellow members and newcomers to provide direction 

into the pathways to dual recovery. 

• Acceptance: 

Twelve-Step fellowships provide 

meetings that 

offer settings for 

recovery. Dual 

recovery meetings 

may offer members and newcomers a setting 

of emotional 

acceptance, support, and empowerment. This condition provides 

opportunities to 

develop a level of 

group trust in 

which people can 

feel safe and able 

to share their 

ideas and feelings 

honestly while 

focusing on recovery from both illnesses. 

Dual recovery 

meetings may 

offer members 

and newcomers 

a setting of

emotional

acceptance, 

support, and 

empowerment. 

Dual Recovery Mutual SelfHelp Approaches 

Dual recovery 12-Step fellowship groups recognize the unique value of people in recovery 

sharing their personal experiences, strengths, 

and hope to help other people in recovery. This 

section provides an overview of emerging selfhelp fellowships and describes a model self-help 

psychoeducational group. 

Self-Help Groups 

Four dual recovery mutual self-help organizations have gained recognition in the field, as 

represented in the literature cited in this section. Each of these fellowships is an independent and autonomous membership organization that is guided by the principles of its own 

steps and traditions (for more information on 

specific steps, see appendix J for each organization’s contact information). Dual recovery 

fellowship members are free to interpret, use, 

or follow the 12 steps in a way that meets 

Special Settings and Specific Populations 191 
their own needs. Members use the steps to 

learn how to manage their addiction and mental disorders together. The following section 

provides additional information on each of 

these specific organizations and the supported 

mutual self-help model. 

1.		Double Trouble in Recovery (DTR). This 

organization provides 12 steps that are 

based on a traditional adaptation of the 

original 12 steps. For example, the identified problem in step one is changed to 

COD, and the population to be assisted is 

changed in step 12 accordingly. The organization provides a format for meetings 

that are chaired by members of the fellowship. 

2. 	Dual Disorders Anonymous. This organization follows a similar format to DTR. 

Like other dual recovery fellowships, the 

organization provides a meeting format 

that is used by group members who chair 

the meetings. 

3. 	Dual Recovery Anonymous. This organization provides 12 steps that are an adapted 

and expanded version of the traditional 12 

steps, similar to those used by DTR and 

Dual Disorders Anonymous. The terms 

“assets” and “liabilities” are used instead 

of the traditional term “character 

defects.” In addition, it incorporates affirmations into three of the 12 steps. Similar 

to other dual recovery fellowships, this 

organization provides a suggested meeting 

format that is used by group members who 

chair the meetings. 

4. 	Dual Diagnosis Anonymous. This organization provides a hybrid approach that 

uses 5 additional steps in conjunction with 

the traditional 12 steps. The five steps differ from those of other dual recovery 

groups in underscoring the potential need 

for medical management, clinical interventions, and therapies. Similar to other dual 

recovery fellowships, this organization 

provides a meeting format that is used by 

group members who chair the meetings. 

The dual recovery fellowships are membership organizations rather than consumer service delivery programs. The fellowships function as autonomous networks, providing a 

system of support parallel to traditional clinical or psychosocial services. Meetings are 

facilitated by members, who are empowered, 

responsible, and take turns “chairing” or 

“leading” the meetings for fellow members 

and newcomers. Meetings are not led by professional counselors (unless a member happens to be a professional counselor and takes 

a turn at leading a meeting), nor are members 

paid to lead meetings. However, the fellowships may develop informal working relationships or linkages with professional providers 

and consumer organizations. 

In keeping with traditional 12-Step principles 

and traditions, dual recovery 12-Step fellowships do not provide specific clinical or counseling interventions, classes on psychiatric 

symptoms, or any services similar to case 

management. Dual recovery fellowships maintain a primary purpose of members helping 

one another achieve and maintain dual recovery, prevent relapse, and carry the message 

of recovery to others who experience dual disorders. Dual recovery 12-Step members who 

take turns chairing their meetings are members of their fellowship as a whole. 

Anonymity of meeting attendees is preserved 

because group facilitators do not record the 

names of their fellow members or newcomers. 

Fellowship members carry out the primary 

purpose through the service work of their 

groups and meetings, some of which are 

described below. 

Groups provide various types of meetings, 

such as step study meetings, in which the discussion revolves around ways to use the fellowship’s steps for personal recovery. 

Another type of meeting is a topic discussion 

meeting, in which members present topics 

related to dual recovery and discuss how they 

cope with situations by applying the recovery 

principles and steps of their fellowship. 

Hospital and institutional meetings may be 

provided by fellowship members to individuals currently in hospitals, treatment programs, or correctional facilities. 

192 Special Settings and Specific Populations 
Fellowship members who are experienced in 

recovery may act as sponsors to newer members. Newcomers may ask a member they 

view as experienced to help them learn to use 

the fellowship’s recovery principles and steps. 

Outreach by fellowship members may provide 

information about their organization to agencies and institutions through in-service programs, workshops, or other types of presentations. 

Access and linkage 

The fellowships are independent organizations based on 12-Step principles and traditions that generally develop cooperative and 

informal relationships with service providers 

and other organizations. The fellowships can 

be seen as providing a source of support that 

is parallel to formal services, that is, participation while receiving treatment and aftercare services. 

Referral to dual recovery fellowships is informal: 

•

•

•

An agency may provide a “host setting” for 

one of the fellowships to hold its meetings. 

The agency may arrange for its clients to 

attend the scheduled meeting. 

An agency may provide transportation for its 

clients to attend a community meeting provided by one of the fellowships. 

An agency may offer a schedule of community 

meetings provided by one of the fellowships 

as a support to referral for clients. 

Common features of dual 

recovery mutual self-help 

fellowships 

Dual recovery fellowships tend to have the following in common: 

•

•

A perspective describing co-occurring disorders and dual recovery. 

A series of steps that provides a plan to 

achieve and maintain dual recovery, prevent 

relapse, and organize resources. 

•

• 

• 

Literature describing the program 

for members and 

the public. 

A format to struc-	

ture and conduct 

meetings in a way 

that provides a 

setting of acceptance and support. 

Plans for establish-	

ing an organizational structure to 

guide the growth



of the member-


ship, that is, a cen­


tral office, fellow-


ship network of 

area intergroups, 

groups, and meetings. An “intergroup” is an 

assembly of people 

made up of delegates from several 

groups in an area. 

It functions as a 

communications 

link upward to the



central office or



offices and out­


ward to all the



area groups it



serves.



Dual recovery 

12-Step 

fellowship 

groups

recognize the

unique value of

people in

recovery sharing their personal experiences, 

strengths, and 

hope to help

other people in

recovery. 

Empirical evidence 

Empirical evidence suggests that participation 

in DTR contributes substantially to members’ 

progress in dual recovery and should be 

encouraged. Specifically, studies found the following positive outcomes: 

• A process analysis indicated that DTR 

involvement at baseline predicted greater levels of subsequent mutual self-help processes 

(e.g., helper-therapy and reciprocal learning 

experiences), which were associated with better drug/alcohol abstinence outcomes 

(Magura et al. 2003). 

Special Settings and Specific Populations 193 
•An examination of the associations between 

DTR attendance, psychiatric medication 

adherence, and mental health outcomes indicated that consistent DTR attendance was 

associated with better adherence to medication, controlling for other relevant variables.

Better adherence to medication was, in turn,

associated with lower symptom severity at 

followup and no psychiatric hospitalization 

during the follow-up period (Magura et al. 

2002). 

Supported mutual self-help 

for dual recovery 

Support Together for Emotional/Mental 

Serenity and Sobriety (STEMSS) is a supported self-help model for people with co-occurring 

disorders. It is a psychoeducational group 

intervention rather than a fellowship or membership organization; therefore it has no “parent organization.” STEMSS uses trained facilitators to initiate, 

implement, and 

maintain support

groups for clients. 

Facilitators may

include professional 

counselors or 

trained clinicians, 

therapists, nurses, 

or paraprofessionals who are 

employed at various 

institutions, treatment programs,

hospitals, or community agencies. In

some instances, 

groups may be

started and facilitated by other individuals trained in the 

STEMSS model. 

in traditional 12-Step programs. Facilitators 

generally are providers who have received 

training in the theoretical concepts, the six 

steps for recovery, psychoeducational content, and group approaches. They are 

encouraged to work with the model in a flexible way, encouraging clients to develop leadership skills to help groups make the transition from psychoeducational groups to 

sources of mutual self-help. Facilitators may 

modify the approach, incorporate additional 

content, develop their own exercises, or 

incorporate the model into the treatment system. Roles commonly filled by the facilitator 

include 

The six steps of the 

program and the

support groups are 

intended to complement participation 

• 

•

•

Psychoeducation: The facilitator provides 

information related to recovery topics, psychiatric symptoms, medications, symptom 

management, coping skills, and other topics. 

Exercises: The facilitator may develop 

group exercises to stimulate discussions and 

group interaction, as well as to help maintain the recovery focus. 

Step discussion: Facilitators initiate discussions regarding the STEMSS six-step 

approach to recovery. 

The STEMSS model may be incorporated into 

the milieu of an agency’s services or may be 

an autonomous group established in a community setting; thus, STEMSS groups are 

supported mutual self-help approaches rather 

than fellowships or consumer service delivery 

organizations. Due to the anonymous nature 

of the groups and the way in which an agency 

uses the model, linkages to STEMSS groups 

would be established on a group-by-group 

basis. For more detail about the STEMSS 

model see TAP 17, Treating Alcohol and 

Other Drug Abusers in Rural and Frontier 

Areas (CSAT 1995e). 

Empirical 

evidence suggests that participation in DTR 

contributes substantially to 

members’ 

progress in dual 

recovery and 

should be 

encouraged. 

Advocating for Dual Recovery 

At this writing, advocacy organizations are at 

various stages of developing information materials, engaging in advocacy efforts to increase 

public awareness, coalition building to develop 

194 Special Settings and Specific Populations 
consensus for services, and providing support

for dual recovery mutual self­help organizations. For contact information on each organization, see appendix J.

Dual Diagnosis Recovery

Network (DDRN)

The DDRN is a program of Foundations

Associates that derives part of its funding from

the Tennessee Department of Mental Health

and Developmental Disabilities and part from

the Tennessee Department of Health, Bureau

of Alcohol and Drug Abuse Services. DDRN

provides

•Dual recovery mutual self­help information

for all areas of the services that are offered

•Education and training through community

programs, inservice training, and workshops, and through State, regional, and

national conferences

•Advocacy and coalition building through

networking and coordinating a statewide

task force that engages chemical dependency and mental health professionals, clients,

and family members

•Information dissemination through the Dual

Network quarterly journal and through the

resource and information clearinghouse

Dual Recovery Empowerment

Foundation (DREF)

The DREF provides training programs and

materials to assist treatment providers, consumer­run programs, and consumer advocacy

organizations in developing education programs for clients, consumers, and family

members. One DREF program is Dual

Recovery Self­Help, which encompasses

information on dual recovery 12­Step fellowships, 12­Step principles for personal recovery, coping and life skills, and forming dual

recovery 12­Step groups and meetings. DREF

also offers Recovery Cultural Cross Training,

which provides a cultural competency

approach to reframe “philosophical barriers”

and explore the histories, common goals,

diversity, and accomplishments of both the

substance abuse recovery culture and the

mental health consumer recovery culture.

National Mental Health

Association

The National Mental Health Association

(NMHA) has expanded its mission to include

COD. In 1999 the NMHA board of directors

adopted a position statement that affirmed

NMHA’s commitment to advocacy, public

education, and service delivery for consumers

with co­occurring substance use and mental

disorders. NMHA focuses its efforts in four

major areas—prevention, treatment,

research, and policy—and is committed to

providing leadership in the substance abuse

and mental health fields in the area of COD.

The organization has a designated area on its

Web site—Alcohol and Drug Abuse,

Addiction and Co­Occurring Disorders—that

contains information, facts, resources, and

links to help mental health consumer advocates increase their knowledge about the key

issues in COD.

National Council on

Alcoholism and Drug

Dependence

The National Council on Alcoholism and Drug

Dependence, Inc. (NCADD) was founded in

1944 and works at the national level on policy

issues related to barriers in education, prevention, and treatment for people with substance

use disorders and their families. NCADD has a

nationwide network of nearly 100 affiliates.

These affiliates provide information and referrals to local services, including counseling and

treatment. NCADD also offers a variety of publications and resources. For more information,

visit http://www.ncadd.org.

Special Settings and Specific Populations 195
Mental health consumer

advocacy organizations

The consumer advocacy movement has a history separate from the substance abuse recovery and 12­Step recovery movements. The

historical roots of the mental health recovery

movement, to a great extent, are related

directly to issues in

the delivery of mental health services.

The modern movement formed in

response to concerns about the

quality of care,

availability of services, and lack of

coordination during

and following deinstitutionalization.

The term “mental

health consumer,”

though controversial to many people

in the movement,

clearly reflects both

a personal and collective relationship

to issues related to

mental health care

services and support. On the other

hand, individuals

in substance abuse

recovery and those

in 12­Step programs do not identify themselves in language that is related to treatment

services. 

The mental health recovery movement and

the substance abuse recovery movement can

develop ways to collaborate in an effort to

support people affected by COD. In order to

collaborate, the movements must engage in a

coalition building process that involves

•Shared goals and visions of the movement

•Histories: identifying and valuing diversity

•Experience, strengths, and skills

•Accomplishments and progress

•Shared goals and visions for dual recovery

The consumer

advocacy movement has a history separate

from the substance abuse	 

recovery and

12­Step recovery movements.

Consumer Organization and

Networking Technical

Assistance Center (CONTAC)

The West Virginia Mental Health Consumer’s

Association’s CONTAC, which receives funding

through SAMHSA’s CMHS, serves as a

resource center for consumers/survivors/

ex­patients and consumer­run organizations

across the United States, promoting self­help,

recovery, and empowerment. The services that

CONTAC provides include informational materials, onsite training and skills­building curricula, and networking and customized activities

promoting self­help, recovery, leadership, business management, and empowerment.

CONTAC also offers the Leadership Academy,

a training program that is designed to help

clients learn how to engage in and develop consumer services.

National Empowerment

Center

The National Empowerment Center has prepared an information packet that includes a

series of journal articles, newspaper articles,

and a listing of organizations and Federal agencies that provide information, resources, and

technical assistance related to substance abuse

and dependence, COD, services, and mutual

self­help support.

196 Special Settings and Specific Populations
Specific Populations 

In recent years, awareness of COD in subpopulations (such as the homeless, criminal justice clients, women with children, adolescents, and those with HIV/AIDS) and concern 

about its implications has been growing. This 

section focuses on three of these subgroups: 

the homeless, those in criminal justice settings, and women. A complete description of 

these clients and related programs is beyond 

the scope of this TIP. However, relevant 

information can be found in a number of 

other TIPs, including TIP 17, Planning for 

Alcohol and Other Drug Abuse Treatment for 

Adults in the Criminal Justice System (CSAT 

1995d); TIP 21, Combining Alcohol and 

Other Drug Abuse Treatment With Diversion 

for Juveniles in the Justice System (CSAT 

1995b); TIP 30, Continuity of Offender 

Treatment for Substance Use Disorders From 

Institution to Community (CSAT 1998c); and 

the forthcoming TIPs Substance Abuse 

Treatment for Adults in the Criminal Justice 

System (CSAT in development e) and 

Substance Abuse Treatment: Addressing the 

Specific Needs of Women (CSAT in development b). This section provides background 

information on the problem of COD in these 

specific populations, describes some model 

programs and Federal initiatives, and offers 

recommendations for programs and services. 

The purpose of this section is to highlight the 

emergence of specific-population COD groups 

and the potential impact of these specialized 

populations on COD treatment. 

Homeless Persons With COD 

Homelessness 

Homelessness continues to be one of the 

United States’ most intractable and complex 

social problems. The Urban Institute estimates that 2.3 to 3.5 million people are homeless annually and 842,000 were homeless in 

February 1996 (Burt and Aron 2000). In New 

York City alone, more than 33,800 New 

Yorkers use the city shelter system each night 

(Bernstein 2002). Despite these statistics, an 

understanding of the diversity of this population and its service needs is incomplete, and 

treatment options are still meager. 

Homeless people have a variety of medical 

problems (Institute of Medicine 1988), including HIV (CSAT 2000e). They are frequent 

victims of and participants in crime (Rahav 

and Link 1995). They also are disproportionately likely to use substances (Fischer and 

Breakey 1987) and to have some form of mental illness (Rossi 1990). 

Homelessness and COD 

Homeless persons with COD are a particularly 

problematic subgroup, one that places unique 

demands on the mental health and substance 

abuse treatment systems. The number of homeless persons with COD has been estimated to 

range from 82,215 to 168,000 in any given week 

(Rahav et al. 1995). 

For most, if not all, homeless clients with 

COD, the impact of substance abuse and 

mental illness bears a direct relationship to 

their homeless status. The ability to maintain 

housing is affected profoundly by substance 

abuse (Hurlburt et al. 1996). Approximately 

70 percent of participants in recent National 

Institute on Alcohol Abuse and Alcoholism 

demonstration projects identified substance 

abuse problems as the primary reason for 

their homelessness in both the first and most 

recent episodes (Leaf et al. 1993; Stevens et 

al. 1993). Among those in shelters, 86 percent 

are estimated to have alcohol problems and 

more than 60 percent have problems with 

illicit drugs (Fischer and Breakey 1991). 

The importance of housing 

Results from the homelessness prevention 

cooperative agreement funded by SAMHSA’s 

CMHS and CSAT suggest the importance of 

providing interventions that address housing. 

Those that ensured housing by “control of 

housing stock” (i.e., programs that make 

housing available or ensure housing) are of 

Special Settings and Specific Populations 197 
particular interest. This study explored the 

interactions among housing, treatment, and 

outcomes for persons with COD who are 

homeless. Researchers noted that after 6 

months, the intervention group for whom 

housing was made available had 12 more days 

of stable housing (during the 6-month period) 

than the comparison group. After 1 year, the 

intervention group had 17 more such days 

(Williams et al. 2001). Among participants 

who had guaranteed access to housing, 

improvements were even greater: At 6 months 

and at 1 year, participants who had guaranteed access to housing showed significant 

short-term and longer-term improvements (on 

all residential measures) compared to a control group who did not have access to housing. The change in the stable housing measure 

represents a 40-day increase from baseline at 

6 months and a 41-day increase at 1 year. In 

contrast, the comparison group showed 

decreases in housing stability. At 6 months 

they had 14 fewer days of homelessness, and 

at 1 year, 7 days. These results are significant, underlining the contribution of stable 

housing to recovery of individuals with COD 

(Williams et al. 2001). 

Another study examined the cost of providing 

supportive housing versus allowing homeless 

people to continue in the homeless assistance 

system, including the cost to the mental 

health, substance abuse treatment, shelter, 

hospital, criminal justice, and other public 

systems. The study reported that psychiatric 

hospital stays were reduced by 28.2 days (49 

percent) for each placement in supportive 

housing. The study found that supportive 

housing dramatically reduced use of other 

public systems by people who were homeless 

and had SMI, including many who also had 

substance abuse problems (Culhane et al. 

2001). 

Service models for homeless 

persons with COD 

The treatment community has responded positively to the needs of this population. It has 

developed several models for homeless clients 

with COD. 

Supportive housing 

Supportive housing typically is housing combined with access to services and supports to 

address the needs of homeless individuals so 

that they may live independently in the community. Generally, it is considered an option 

for individuals and families who have either 

lived on the streets for longer periods of time 

and/or who have needs that can be best met 

by services accessed through their housing. 

Although the evidence base consists of a small 

number of studies that vary in methodological 

rigor and population focus, the results indicate that housing with supports in any form is 

a powerful intervention that improves the 

housing stability of individuals with substance 

abuse and mental disorders, including those 

who have been homeless (Hurlburt et al. 

1996; Rog and Gutman 1997; Shinn et al. 

1991). However, many of the same studies 

also indicate that substance abuse is a major 

cause of housing loss and that individuals 

with COD fare less well in housing than those 

with other disabilities (Shern et al. 1997). 

The Pathways to Housing program developed 

by Tsemberis (Tsemberis et al. 2003; 

Tsemberis and Eisenberg 2000) is a form of 

supportive housing designed to serve a highly 

visible and vulnerable segment of New York’s 

homeless population (persons with COD who 

live in the streets, parks, subway tunnels, and 

similar places). The Pathways program 

adopts a client perspective and offers clients 

the option of moving from the streets directly 

into a furnished apartment of their own 

(Tsemberis and Eisenberg 2000). However, 

clients must agree to receive case management 

and accept a representative payee to ensure 

that rent/utilities are paid and for resource 

management. Pathways also uses Assertive 

Community Treatment teams to offer clients 

their choice of a wide array of support services in twice-monthly sessions. Vocational, 

health, psychiatric, substance abuse, and 

other services are among the options. 

198 Special Settings and Specific Populations 
A 2-year longitudinal, random assignment, 

clinical trial study evaluating the effectiveness 

of the Pathways program as compared to continuum of care programs (i.e., programs 

where clients move from one level of housing 

to the next least restrictive level) was conducted with 225 individuals who were homeless and had mental disabilities; 90 percent 

also had co-occurring substance use disorders. Housing outcomes were significantly 

better for the Pathways group at the 6-, 12-, 

18-, and 24-month followup points. For example, between 18 and 24 months the Pathways 

group members spent 4 percent of their time 

literally homeless, compared to 23 percent for 

the continuum group; they also spent 74 percent of their time in stable housing, compared 

to 34 percent for the continuum group. In 

addition, Pathways participants were not 

more symptomatic at any point, and they did 

not differ from the continuum group on use of 

alcohol or other substances. However, the 

greater effectiveness of the Pathways program 

in comparison with other programs for the 

substance abuse, mental health, and other 

problems of these homeless clients with COD 

remains to be established. 

For most, if not 

all, homeless 

clients with 

COD, the

impact of substance abuse 

and mental illness bears a 

direct relationship to their

homeless status. 

Housing contingent on 

treatment 

Milby and colleagues (1996) found promise in 

an intervention that added contingent work 

therapy and housing to a regular day treatment regimen. They compared a standard 

treatment that featured twice-weekly treatment sessions and referrals for housing and 

vocational services with an enhanced treatment program that included weekday day 

treatment (for 5.5 hours per day) and a work 

therapy component that provided clients with 

a salary great enough to afford subsidized 

housing (contingent upon drug-free urine 

samples). Clients in day treatment with the 

housing and vocational component had 36 

percent fewer cocaine-positive urine toxicologies at 2 months after treatment and 18 percent fewer at 6 months compared to clients in 

the standard outpatient program. 

However, the study 

did not focus solely 

on clients with 

COD; in fact, it 

excluded clients 

with active psychosis (Milby et al. 

1996). 

In a later study, 

Milby and colleagues (2000) compared two different 

day treatment programs, one that 

added abstinent 

contingent employment and housing 

and one that did 

not. Although the 

study excluded 

clients with psychotic disorders, 

three fourths met 

Axis I diagnostic 

criteria for other 

mental disorders. 

Those who received 

the extra vocational and housing services 

achieved longer periods of abstinence than 

those who did not (the former having a median of approximately 9 consecutive weeks of 

abstinence out of 24 weeks, and the latter 

only 3–4 consecutive weeks during the same 

period). The clients who received these added 

services also showed greater gains in measures of homelessness and employment (Milby 

et al. 2000). 

Housing and treatment 

integrated 

In New York City two specialized shelters are 

addressing the needs of people who are homeless and who have COD: the Greenhouse 

Program and the Salvation Army shelter. The 

Special Settings and Specific Populations 199 
Greenhouse Program is a 28-bed modified 

therapeutic community (TC) shelter for hardto-reach homeless persons with COD. Staff at 

the program are trained to address both mental and substance use disorder issues. 

Developed in 1991 by Bellevue Hospital, this 

was one of the first specialized shelter programs in the City to treat this population 

(Galanter et al. 1993; Silberstein et al. 1997). 

The second is the Salvation Army shelter. 

Developed in 1998 by the Salvation Army in 

association with National Development and 

Research Institutes, Inc., “Kingsboro 

New Beginnings” is a modified TC for 

engagement and retention in an 80-bed 

shelter. Designed for hard-to-reach people who are homeless and have co-occurring mental and substance use disorders—those who are seeking shelter, but 

not necessarily treatment—this program 

brought people with COD who were 

homeless into a specialized shelter setting, using strategies to engage them in 

mental health services and substance 

abuse treatment and prepare them for 

housing (Sacks et al. 2002). 

In a series of papers, Sacks and colleagues report on a system of care for 

people who are homeless that uses a 

modified therapeutic community (MTC) 

approach (see chapter 6 for additional 

information on the MTC model). Clients 

move from a residential facility to colocated supportive housing as they progress 

though stages of treatment. Engagement, primary treatment, and planning for re-entry 

take place in the residential facility; re-entry 

takes place in the supportive housing program. The research indicated that these 

clients made significant improvement (compared to treatment-as-usual) on measures of 

substance use and employment during residential treatment (De Leon et al. 1999, 

2000c). These gains appeared to stabilize during the supportive housing phase (Sacks et al. 

2003a). The authors concluded: 

sustained and, in some cases, strengthened by 

the use of TC-oriented supported housing as 

an aftercare strategy. The particular gains in 

employment and symptom relief are noteworthy in that they speak to core problems of the 

homeless MICA [mentally ill chemical abusing] population. Combined with the capacity 

to maintain low levels of crime and substance 

use, supported housing can be seen as an 

important and effective way of achieving continuing progress for this population (Sacks et 

al. 2003a). 

These pilot findings suggest that the positive 

behavioral change associated with completion 

of 12 months of residential treatment can be 

Advice to the Counselor: 

Working With Homeless Clients 

With COD 

The consensus panel recommends the following in 

working with homeless clients with COD: 

• Address the housing needs of clients. 

• Help clients obtain housing. 

• Teach clients skills for maintaining housing. 

• Work closely with shelter workers and other 

providers of services to the homeless. 

• Address real-life issues in addition to housing, such as 

substance abuse treatment, legal and pending criminal justice issues, Supplemental Security 

Insurance/entitlement applications, issues related to 

children, healthcare needs, and so on. 

Criminal Justice Populations 

Prevalence of COD 

Estimates of the rates of severe mental and 

substance use disorders in jail and prison 

populations have varied between 3 and 16 

percent (Peters and Hills 1993; Regier et al. 

1990; Steadman et al. 1987). A U.S. 

Department of Justice special report (Ditton 

1999) estimated that 16 percent of State 

prison inmates, 7 percent of Federal inmates, 

16 percent of those in local jails, and about 

16 percent of probationers reported either a 

mental disorder or an overnight stay in a 

mental hospital during their lifetime (Ditton 

200 Special Settings and Specific Populations 
1999). Substance abuse is also common in the 

criminal justice population. Offenders in the 

U.S. Department of Justice Survey report a 

high incidence of drug and alcohol abuse. 

One third were alcohol dependent, while 6 in 

10 were under the influence of alcohol or 

drugs at the time of offense (Ditton 1999). 

Rationale for treatment 

The rationale for providing substance abuse 

treatment in prisons is based on the wellestablished relationship between substance 

abuse and criminal behavior. According to 

Ditton (1999), offenders with mental illness 

were likely to be using substances when they 

committed their convicting offense and likely 

to be incarcerated for a violent crime. On the 

other hand, the majority of probationers with 

mental disorders (approximately three quarters) have not been involved in violent crime. 

The overall goal of substance abuse treatment 

for criminal offenders, especially for those 

who are violent, is to reduce criminality. 

Treatment features and 

approaches 

Several features distinguish the programs currently in place to treat inmates with COD from 

other substance abuse treatment programs: 

•Staff are trained and experienced in treating 

both mental illness and substance abuse. 

•Both disorders are treated as “primary.” 

•Treatment services are integrated whenever 

possible. 

•Comprehensive treatment is flexible and individualized. 

•The focus of the treatment is long-term. 

Treatment approaches used with other populations (e.g., TCs, interventions using cognitive–behavioral approaches, relapse prevention strategies, and support groups) can be 

adapted to suit the particular needs of offenders with COD. Common modifications 

described in the literature (Edens et al. 1997; 

Peters and Hills 1997; Peters and Steinberg 

2000; Sacks and Peters 2002) include 

• Smaller caseloads 

• Shorter and simplified meetings 

• Special attention to criminal thinking 

• Education about medication and COD 

• An effort to minimize confrontation 

The importance of postrelease treatment and 

followup 

In the last decade, a number of studies have 

established the importance of linking institutional services to community services (of various kinds). The initial rationale for providing 

aftercare subsequent to prison-based treatment was to ease the abrupt transition of the 

offender from prison to community, thus promoting reintegration while monitoring the 

offender’s behavior in a semi-controlled environment (Clear and Braga 1995; McCarthy 

and McCarthy 1997). Significant reductions 

in recidivism were obtained; reductions were 

larger and sustained for longer periods of 

time when institutional care was integrated 

with aftercare programs. Examples are TC 

work-release (Butzin et al. 2002; Inciardi et 

al. 2001; Martin et al. 1999) or other community-based treatment such as post-prison TC 

(Griffith et al. 1999; Hiller et al. 1999; Knight 

et al. 1997; Wexler et al. 1999) or cognitive– 

behavioral programs (Johnson and Hunter 

1995; Peters et al. 1993; Ross et al. 1988). 

Longer-term followup studies of TC in-prison 

plus aftercare programs have reported findings indicating that treatment effects producing lower rates of return to custody may persist for up to 5 years (Prendergast et al. 

2004). 

Recently, the National Institute on Drug 

Abuse has established the Criminal Justice 

Drug Abuse Treatment System. This initiative 

funds regional research centers that are 

intended to forge partnerships between substance abuse service providers and the crimiSpecial Settings and Specific Populations 201 
nal justice system to design and test 

approaches to the better integration of inprison treatment and post-prison services. 

Examples of programs in 

prisons 

The Clackamas County program 

(Oregon City, Oregon) 

Clackamas County offers two related programs 

for persons in jails. While incarcerated, 

inmates are offered pretreatment services in 

which psychoeducational and preliminary 

treatment issues are discussed. Discussion sessions are staffed by both a substance abuse 

treatment counselor, employed by the Mental 

Health Center, and a corrections counselor 

who is certified to provide substance abuse 

treatment services. Inmates are housed in a 

separate unit, creating some milieu intervention factors. 

Many of these inmates are transferred to the 

Center’s Corrections Substance Abuse 

Program, when space is available. The 

Corrections Substance Abuse Program is a 

residential treatment program within a work 

release setting. During the first phase clients 

stay in-house exclusively. With successful 

Advice to the Counselor: 

Providing Community Supervision 

for Offenders With COD 

Source: Adapted from Peters and Hills 1997. 

The panel recommends the following strategies for community supervision of offenders with COD: 

• Recognize special service needs. 

• Give positive reinforcement for small successes and 

progress. 

• Clarify expectations regarding response to supervision. 

• Use flexible responses to infractions. 

• Give concrete (i.e., not abstract) directions. 

• Design highly structured activities. 

• Provide ongoing monitoring of symptoms. 

progress, they are allowed to seek work in the 

community. On completion of the program, 

clients are transitioned to outpatient care in 

the community with continued monitoring by 

probation or parole. 

Clackamas County also offers intensive outpatient programs focused on different client 

needs. Through close consultation with the 

local criminal justice system, offenders under 

electronic surveillance receive intensive outpatient care. Programming is gender based, 

with parallel programming for men and 

women. Sufficient progress transitions the 

client to less intensive outpatient care. 

The Clackamas County program for offenders 

under electronic surveillance was developed 

in close consultation with the criminal justice 

system, with staff members from that system 

serving as co-facilitators for treatment groups 

in the program. The highest incidence of personality disorders of any clients in Clackamas 

County’s substance abuse treatment programs 

have been found in this particular population 

of offenders. Consequently, skills building to 

address such mental health issues as identifying thinking errors, anger management, and 

conflict resolution are emphasized and form 

an integral part of this intervention. A subprogram (“Bridges”) works 

specifically with clients who have 

COD, providing case management and treatment services. 

Most Bridges clients have severe 

and persistent mental illness 

with histories of school and work 

failures; consequently, the intervention is intensive, stepwise, 

and structured, with the opportunity for support in developing 

social and work skills. 

Another effort coordinated with 

criminal justice has been the 

intensive outpatient subprogram, drug court. To participate, clients must be of nonfelony status and can have their 

202 Special Settings and Specific Populations 
misdemeanor charges expunged by completion of the year-long program. This program, 

too, is conceived as a stepwise intervention. 

The Colorado Prison program 

In response to the increasing number of 

inmates with SMI, the Colorado Department of 

Corrections contracted with a private not-forprofit agency during the mid-1990s to develop 

Personal Reflections, a modified TC program. 

A separate 32-bed unit with a planned stay of 

15 months, Personal Reflections is located in 

Pueblo at the San Carlos Correctional Facility, 

which houses only inmates with mental illness. 

The goal of the program is to foster personal 

change and to reduce the incidence of return 

to a criminal lifestyle. Personal Reflections 

uses TC principles and methods as the foundation for recovery and to provide the structure for a cognitive–behavioral curriculum 

focused on the triple issues of substance 

abuse, mental illness, and criminal thinking 

and activity. At the same time, as is central to 

TC programming, a positive peer culture is 

employed to facilitate behavior change. 

The Personal Reflections modified TC uses 

psychoeducational classes to increase an 

inmate’s understanding of mental illness, 

addiction, the nature of COD, drugs of use 

and abuse, and the connection between 

thoughts and behavior. These classes also 

teach emotional and behavioral coping skills. 

Therapeutic interventions in the modified TC 

include (1) core groups to process personal 

issues, (2) modified encounter groups that 

address maladaptive behaviors and personal 

responsibility, and (3) peer groups to provide 

feedback and support. 

Empirical evidence 

The Personal Reflections program is being 

evaluated by a study design that randomly 

assigned and compared two groups, modified 

TC and services-as-usual (i.e., a mental health 

services approach). The results obtained from 

an intent-to-treat analysis of all study entries 

showed that inmates randomized into the MTC 

group had significantly lower rates of reincarceration compared to those in the mental 

health services only group (Sacks et al. 2004). 

Because of the stigma associated with the 

combination of substance abuse, co-occurring 

mental illness, and a criminal record, this 

group of offenders will face barriers to being 

accepted into an aftercare program. They 

also will have difficulty locating effective programs for their complex problems that 

require specialized treatment (Broner et al. 

2002). 

Women 

Women with co-occurring disorders can be 

served in the same types of mixed-gender cooccurring programs and with the strategies 

mentioned elsewhere in this TIP. However, 

specialized programs for women with COD 

have been developed primarily to address 

pregnancy and childcare issues as well as certain kinds of trauma, violence, and victimization that may best be dealt with in womenonly programs. 

Responsibility for care of dependent children 

is one of the most important barriers to entering treatment according to a major survey of 

public alcohol dependence authorities, treatment programs, and gatekeepers in 39 communities (CSAT 2001). Women who enter 

treatment sometimes risk losing public assistance support and custody of their children, 

making the decision to begin treatment a difficult one (Blume 1997). Women accompanied 

by their children into treatment can be successful in treatment. A CSAT study of 50 

grantees in the Residential Women and 

Children and Pregnant and Postpartum 

Women programs reported that the 6- to 12­

month treatment program had positive results 

according to a number of outcome measures 

(CSAT 2001). 

Few women-centered or women-only outpatient co-occurring programs have been 

described, and most outpatient groups are 

mixed gender. However, Comtois and Ries 

(1995) concluded that gender-specific specialSpecial Settings and Specific Populations 203 
ized programming may make very significant 

differences. They found that before specialized programming, women only accounted for 

20 percent of group attendance, yet made up 

40 percent of census in a large integrated 

COD treatment program for those with SMI. 

After women-only specialized programming 

was developed, the 40 percent census then 

accounted for 50 percent of group visits. 

Women attendees commented that they did 

not feel comfortable in mixed groups, especially in the early phases of treatment, but 

felt very differently when they had their own 

groups. 

It is the responsibility of the program to 

address the specific needs of women, and 

mixed-gender programs need to be made 

more responsive to women’s needs. Women in 

mixed-gender outpatient programs require 

very careful and appropriate counselor 

matching and the availability of specialized 

women-only groups to address sensitive issues 

such as trauma, parenting, stigma, and selfesteem. Strong administrative policies pertaining to sexual harassment, safety, and language must be clearly stated and upheld. 

These same issues occur in residential programs designed for women who have multiple 

and complex needs and require a safe environment for stabilization, intensive treatment, and an intensive recovery support 

structure. Residential treatment for pregnant 

women with co-occurring disorders should 

provide integrated co-occurring treatment 

and primary medical care, as well as attention to other related problems and disorders. 

The needs of women in residential care 

depend in part on the severity and complexity 

of their co-occurring mental disorders. Other 

issues meriting attention include past or present history of domestic violence or sexual 

abuse, physical health, and pregnancy or 

parental status. 

Substance abuse and mental 

health problems in women 

While alcohol, marijuana, and cocaine continue to be problems, heroin, methamphetamine, 

and new drugs like OxyContin® have gained 

popularity among women. In general, drugs of 

abuse today are more available and less expensive than in the past. The previously lower rate 

of addictions in women compared to men 

appears to be vanishing, as the rate of substance abuse among young females has become 

almost equivalent to that of young males. For 

example, according to SAMHSA’s 2002 

National Survey on Drug Use and Health, pastmonth use of methamphetamine reported by 

women was 0.2 percent, versus 0.3 percent 

reported by men (Office of Applied Studies 

2003b). 

Women and men have differing coping mechanisms and symptom profiles. As compared to 

their male counterparts, women with substance use disorders have more mental disorders (depression, anxiety, eating disorders, 

and posttraumatic stress disorder [PTSD]) 

and lower self-esteem. While women with substance use disorders have more difficulty with 

emotional problems, their male counterparts 

have more trouble with functioning (e.g., 

work, money, legal problems). See the TIP 

Substance Abuse Treatment: Addressing the 

Specific Needs of Women (CSAT in development b) for more on the psychological impact 

of substance abuse on women. 

Treatment for substance abuse in women 

should emphasize the importance of relationships, the link between relationships and substance abuse (many women continue to use 

with a partner), and the importance of relationships with children as a motivator in 

treatment. The stigma attached to females 

who abuse substances functions as a barrier 

to treatment, as does the lack of provision for 

children. 

204 Special Settings and Specific Populations 
Pregnancy and co-occurring 

disorders 

Pregnancy can aggravate or diminish the symptoms of co-occurring mental illness. Worsening 

symptoms of mental illness can result from hormonal changes that occur during pregnancy; 

lactation; medications given during pregnancy 

or delivery; the stresses of pregnancy, labor, 

and delivery; and adjusting to and bonding 

with a newborn (Grella 1997). Women with cooccurring disorders sometimes avoid early prenatal care, have difficulty complying with 

healthcare providers’ instructions, and are 

unable to plan for their babies or care for them 

when they arrive. According to the literature, 

women with anxiety disorders or personality 

disorders are at increased risk for postpartum 

depression (Grella 1997). 

Many pregnant women with co-occurring disorders are distrustful of substance abuse 

treatment and mental health service 

providers, yet they are in need of multiple 

services (Grella 1997). One concern is 

whether the mother can care adequately for 

her newborn. For her to do so requires family-centered, coordinated efforts from such 

caregivers as social workers, child welfare 

professionals, and the foster care system. 

Issues to address with co-occurring 

mental illness 

It is particularly important to make careful 

treatment plans during pregnancy for women 

with mental disorders that include planning for 

childbirth and infant care. Women often are 

concerned about the effect of their medication 

on their fetuses. Treatment programs should 

work to maintain medical and mental stability 

during the client’s pregnancy and collaborate 

with other healthcare providers to ensure that 

treatment is coordinated. 

When women are parenting, it can often 

retrigger their own childhood traumas. 

Therefore, providers need to balance growth 

and healing with coping and safety. Focusing 

on the woman’s interest in and desire to be a 

good mother, the sensitive counselor will be 

alert to the inevitable guilt, shame, denial, 

and resistance to dealing with these issues, as 

the recovering woman increases her awareness of effective parenting skills. Providers 

also need to allow for evaluation over time for 

women with COD. Reassessments should 

occur as mothers progress through treatment. 

Pharmacologic considerations 

From a clinical standpoint, before giving any 

medications to pregnant women it is of vital 

importance that they understand the risks 

and benefits of taking these medications and 

that they sign informed consent forms verifying that they have received and understand 

the information provided to them. Certain 

psychoactive medications may be associated 

with birth defects, especially in the first 

trimester of pregnancy, and weighing potential risk/benefit is important. In most cases, a 

sensible direction can be found; however, this 

needs expert advice and consideration by a 

physician and pharmacist familiar with working with pregnant women with mental disorders. Since pregnant women often present to 

treatment in mid to late second trimester and 

polydrug use is the norm rather than the 

exception (Jones et al. 1999), it is important 

first to screen these women for dependence on 

the classes of substances that can produce a 

life-threatening withdrawal for the mother: 

alcohol, benzodiazepines, and barbiturates. 

These substances, as well as opioids, can 

cause a withdrawal syndrome in the baby, 

who may need treatment. Pregnant women 

should be made aware of any and all wraparound services to assist them in managing 

newborn issues, including food, shelter, medical clinics for innoculations, etc., as well as 

programs that can help with developmental or 

physical issues the infant may experience as a 

result of alcohol/drug exposure. For more on 

pharmacologic considerations for pregnant 

women, see appendix F. 

Special Settings and Specific Populations 205 
Postpartum depression 

The term “postpartum depression” encompasses: 

•Postpartum or maternity “blues,” which 

affects up to 85 percent of new mothers 

•Postpartum depression, which affects 

between 10 and 15 percent of new mothers 

•Postpartum psychosis, which develops following about one per 500–1,000 births, according to some studies (Steiner 1998) 

Postpartum “blues” is transient depression 

occurring most commonly within 3–10 days 

after delivery. There is evidence that the 

“blues” are precipitated by progesterone 

withdrawal (Harris et al. 1994). Prominent in 

its causes are a woman’s emotional letdown 

following the excitement and fears of pregnancy and delivery, the discomforts of the 

period immediately after giving birth, fatigue 

from loss of sleep during labor and while hospitalized, energy expenditure at labor, anxieties about her ability to care for her child at 

home, and fears that she may be unattractive 

to her partner. Symptoms include weepiness, 

insomnia, depression, anxiety, poor concentration, moodiness, and irritability. These 

symptoms tend to be mild and transient, and 

women usually recover completely with rest 

and reassurance. Anticipation and preventive 

reassurance throughout pregnancy can prevent postpartum blues from becoming a problem. Women with sleep deprivation should be 

assisted in getting proper rest. Followup care 

should ensure that the woman is making sufficient progress and not heading toward a 

relapse to substance use. 

Figure 7-1 lists the criteria for major depressive episode, of which postpartum onset is one 

specifier. Not all instances of postpartum 

depression meet the criteria for major depressive episode; they may have fewer than five 

symptoms. 

According to the DSM-IV-TR (APA 2000), for 

a depressive episode to be characterized 

“with postpartum onset,” it must begin within 

4 weeks postpartum. Risk factors for postpartum depression include prior history of nonpostpartum depression or psychological distress during pregnancy, other prepregnancy 

mental diagnosis, or family history of mental 

disorder (American Psychiatric Association 

[APA] 2001; Nielsen Forman et al. 2000; 

Steiner 2002; Webster et al. 2000). Prospects 

for recovery from postpartum depression are 

good with supportive psychological counseling 

Figure 7-1 

Criteria for Major Depressive Episode 

Source: APA 2000. 

At least five of the following symptoms present during the same 2-week period, representing a change from previous functioning; one of the symptoms is either depressed mood or loss of interest or pleasure: 

• Depressed mood most of the day, nearly every day 

• Diminished interest or pleasure in activities 

• Significant weight loss 

• Insomnia or hypersomnia nearly every day 

• Psychomotor agitation or retardation nearly every day 

• Fatigue or loss of energy 

• Feelings of worthlessness or excessive or inappropriate guilt 

• Diminished ability to think or concentrate, or indecisiveness 

• Recurrent thoughts of death, recurrent suicidal ideation, or a suicide attempt 

206 Special Settings and Specific Populations 
accompanied as needed by pharmacological 

therapy (Chabrol et al. 2002; Cohen et al. 

2001; O’Hara et al. 2000). Antidepressants, 

anxiolytic medications, and even electroconvulsive therapy have all been successful in 

treating postpartum depression (Griffiths et 

al. 1989; Oates 1989; Varan et al. 1985). 

Because some medications pass into breast 

milk and can cause infant sedation, it is best 

to consult an experienced psychiatrist or 

pharmacist for details. Patients with postpartum depression need to be monitored for 

thoughts of suicide, infanticide, and progression of psychosis in addition to their response 

to treatment. 

Postpartum psychosis is a serious mental disorder. Women with this disorder may lose 

touch with reality and experience delusions, 

hallucinations, and/or disorganized speech or 

behavior. Women most likely to be diagnosed 

with postpartum psychosis are those with previous diagnoses of bipolar disorder, 

schizophrenia, or schizoaffective disorder or 

women who had a major depression in the 

year preceding the birth (Kumar et al. 1993). 

Other studies reviewed by Marks and colleagues (1991) indicate that other risk factors 

for postpartum psychosis include previous 

depressive illness or postpartum psychosis, 

first pregnancy, and family history of mental 

illness. Recurrence of postpartum psychosis 

in the next pregnancy occurs in 30–50 percent 

of women (APA 2000). Peak onset is 10–14 

days after delivery but can occur any time 

within 6 months. The severity of the symptoms mandates pharmacological treatment in 

most cases, and sometimes, hospitalization. 

The risk of self-harm and/or harm to the 

baby needs to be assessed, and monitoring of 

mother–infant pairs by trained personnel can 

limit these risks. 

Women, trauma, and 

violence 

It is estimated that between 55 and 99 percent 

of women in substance abuse treatment have 

had traumatic experiences, typically childhood physical or sexual abuse, domestic violence, or rape. Of these, between 33 and 59 

percent have been found to be experiencing 

current PTSD; yet, historically, few substance abuse treatment programs assess for, 

treat, or educate clients about trauma 

(Najavits 2000). This deficiency is a serious 

one, given the multiplying consequences of 

failure to address this problem. Greater violence leads to more serious substance abuse 

and other addictions (e.g., eating disorders, 

sexual addiction, and compulsive exercise), 

along with higher rates of depression, selfmutilation, and suicidal impulses. Addiction 

places women at higher risk of future trauma, 

through their associations with dangerous 

people and lowered self-protection when using 

substances (e.g., going home with a stranger 

after drinking). 

Models for women’s trauma 

recovery 

Clearly, effective ways of addressing the trauma-specific needs of women with COD are 

essential. Fortunately, a number of models are 

emerging, many with data demonstrating their 

efficacy. Harris and Fallot have described the 

core elements of a trauma-informed addictions 

program as follows (2001, p. 63): 

• “The program must have a commitment to 

teaching explanations that integrate trauma 

and substance use.” The authors stress the 

need to help clients understand the interaction between trauma and substance use. 

They encourage the use of “self-soothing 

mechanisms” to help trauma survivors deal 

with symptoms such as flashbacks without 

resorting to substance use. (See “Grounding” 

in the discussion of PTSD, appendix D.) 

• “The milieu must promote consumer empowerment and relationship building as well as 

healing.” The authors stress the importance 

of building strengths, providing an opportunity for caring connections through group 

work and informal sharing, and establishing 

a milieu that is “warm, friendly, and nurturing.” 

Special Settings and Specific Populations 207 
•“Each woman must be encouraged to develop certain crossover skills that are equally 

important in recovery from trauma and 

chemical dependency.” Examples of such 

skills include enhancing self regulation, 

limit setting, and building self-trust. 

•“A series of ancillary services help a woman 

to continue her recovery once she leaves a 

structured program.” Examples of areas to 

be addressed include legal services (e.g., 

child custody issues, childcare issues), safe 

housing (e.g., housing that accepts children), and health care (e.g., prenatal care, 

gynecology, pediatrics). 

•“The program avoids the use of recovery 

tactics that are contraindicated for women 

recovering from physical and sexual violence.” For many women, these include 

shaming, moral inventories, confrontation, 

emphasis on a higher power, and intrusive 

monitoring. Many practitioners find that 

alternatives to the 12-Step model are helpful for some women (Kasl 1992; Women for 

Sobriety 1993). On the other hand, many 

women have benefited from 12-Step programs. Gender-specific 12-Step meetings 

may compensate for the shortcoming of 

mixed gender or predominantly male 

programs. 

While a detailed description of trauma recovery model programs is beyond the scope of this 

TIP, readers should be aware that there are a 

number of emerging models available for use. 

Many are supported by published materials, 

such as workbooks with session guides that aid 

in implementation. Examples include the following: 

•The Trauma Recovery and Empowerment 

Model (TREM) is a group approach to healing from the effects of trauma. TREM combines the elements of social skills training, 

psychoeducational and psychodynamic 

techniques, and emphasizes peer support, 

which have proven to be highly effective 

approaches with survivors. A 33-session 

guide book for clinicians is available 

(Harris and Community Connections 

Trauma Work Group 1998). 

•Seeking Safety offers a manual-based, cognitive–behavioral therapy model consisting 

of 25 sessions which has been used in a 

number of studies with women who have 

substance dependence and co-occurring 

PTSD (Najavits 2000, 2002). 

•Helping Women Recover: A Program for 

Treating Addiction is an integrated program with a separate version for women in 

the criminal justice system. This model integrates theoretical perspectives of substance 

abuse and dependence, women’s psychological development, and trauma (Covington 

1999). 

•The Addiction and Trauma Recovery 

Integration Model is designed to assess and 

intervene at the body, mind, and spiritual 

levels to address key issues linked to trauma and substance abuse experiences (Miller 

and Guidry 2001). 

•Trauma Adaptive Recovery Group 

Education and Therapy (TARGET) aims to 

help clients replace their stress responses 

with a positive approach to personal and 

relational empowerment. TARGET has 

been adapted for deaf clients and for those 

whose primary language is Spanish or 

Dutch (Ford et al. 2000). 

For more detailed information, including 

individual and other models of trauma healing, see the forthcoming TIPs Substance 

Abuse Treatment: Addressing the Specific 

Needs of Women (CSAT in development b) 

and Substance Abuse Treatment and Trauma 

(CSAT in development d). 

The women, co-occurring 

disorders, and violence study 

Three SAMHSA Centers—CSAT, CMHS, and 

the Center for Substance Abuse Prevention— 

collaborated on a nine-site study to develop 

systems of care for women with co-occurring 

disorders who also were survivors of violence 

(the study ended in 2003). Each site was charged with 

implementing an intervention that models integrated 

208 Special Settings and Specific Populations 
care and conducting a qualitative evaluation 

of the methods used. The work clearly underlined the need for integrated services, the 

need to address trauma and violence, and the 

need to include children with their mothers in 

treatment. Two of the the participating sites 

are featured below. 

The sites also have identified many issues for 

children whose mothers had co-occurring disorders. In four of the nine sites in this study, 

an additional subset study focused on the 

children of women who participated in the 

study. The “Cooperative Agreement to Study 

Children of Women with Alcohol, Drug Abuse 

and Mental Health (ADM) Disorders who 

Have Histories of Violence” sought to generate and apply empirical knowledge about the 

effectiveness of trauma-informed, culturally 

relevant, age-specific intervention models 

for children 5 to 10 years of age. The 

intervention was driven by concern for children who experienced stress as a result of witnessing violence and were at risk for a multitude of problems as they grew older, including COD. 

Community Connections 

Community Connections is a comprehensive 

nonprofit human services agency serving an 

urban population in Washington, D.C. 

Community Connections was the lead agency 

in the District of Columbia Trauma 

Collaboration Study (DCTCS), one of nine 

sites in the SAMHSA research effort to examine the effectiveness of services for female 

trauma survivors with COD. The DCTCS 

served more than 150 women in the experimental condition at two agencies in 

Washington, D.C. All had histories of sexual 

and/or physical abuse and had co-occurring 

substance use and mental disorders. 

For the past decade, Community Connections 

has focused both clinical and research efforts 

on the needs of trauma survivors. The agency 

has developed trauma-specific services, examined the prevalence and impact of trauma in 

the lives of individuals diagnosed with serious 

mental disorders, and developed training and 

consultation models addressing trauma. In 

the first 2 years of the SAMHSA project, 

Community Connections developed a comprehensive, integrated, trauma-focused network 

of services. A quasi-experimental research 

project that occurred from 2000 to 2003 

assessed the impact of the key intervention 

components: 

1. 	TREM groups. The TREM group treatment intervention was developed by clinicians at Community Connections with considerable input from consumers. TREM is 

a 33-session intervention that uses a psychoeducational focus and skill-building 

approach, emphasizes survivor empowerment and peer support, and teaches techniques for self-soothing, boundary maintenance, and current problemsolving. A 

more abbreviated version (24 sessions) was 

developed for agencies to use in a 3- to 6­

month time frame. TREM has been published as a fully manualized leader’s guide 

(Harris and Community Connections 

Trauma Work Group 1998), and in a selfhelp workbook format titled Healing the 

Trauma of Abuse (Copeland and Harris 

2000). 

2. 	Integrated Trauma Services Teams 

(ITSTs). ITSTs provide an integrated, 

comprehensive package of services, 

include consumer/survivor/recovering persons (C/S/Rs) in central roles, and are 

responsive to issues of gender and culture. 

Embedded in an integrated network of 

programs offering a full range of necessary 

support services, ITSTs are composed of 

primary clinicians cross-trained in trauma, mental health, and substance abuse 

domains. The teams provide services 

addressing these domains and the complex 

interactions among them simultaneously 

and in a closely coordinated way. 

3. 	Collateral Groups. Several additional 

trauma-informed groups have been developed for women in the study. These modules are explicitly integrative, addressing 

the relationships among trauma, mental 

Special Settings and Specific Populations 209 
health, and substance abuse concerns. 

Group modules are: Trauma Informed 

Addictions Treatment, Parenting Issues, 

Spirituality and Trauma Recovery, 

Domestic Violence, Trauma Issues 

Associated with HIV Infection, and 

Introduction to Trauma Issues for Women 

on Inpatient or Short-Stay Units. 

4. 	Women’s Support and Empowerment 

Center (peer support). Project C/S/Rs 

developed and offer a variety of peer-run 

services, including a Peer Representative 

program providing support, companionship, and advocacy within a women’s peer 

center, open 5 days a week to women in 

the program. 

Data from the DCTCS suggested that this 

TREM-based integrative approach was effective in facilitating recovery from substance use 

disorders and other mental illness. Pilot data 

from four different clinical sites indicate 

TREM’s potential benefits in several domains: 

mental health symptom reduction, decreased 

utilization of intensive services such as inpatient hospitalization and emergency room visAdvice to the Counselor: 

Treatment Principles and Services for Women With COD 

Source: Adapted from Finkelstein et al. 1997. 

The panel recommends the following treatment principles and services for women. 

A report from the National Women’s Resource Center (Finkelstein et al. 1997) reviews the literature on women’s programs and finds that these models have many basic tenets in common. The 

overarching principle is that the provision of comprehensive services and treatment needs to be 

in accord with the context and needs of women’s daily lives. Recommendations based on the 

Center’s review include: 

• Identify and build on each woman’s strengths. 

• Avoid confrontational approaches (or, as has been stated previously, supportive interventions are 

preferred to confrontational interventions for persons with COD, especially in the early stages of 

treatment). 

• Teach coping strategies, based on a woman’s experiences, with a willingness to explore the 

woman’s individual appraisals of stressful situations. 

• Arrange to meet the daily needs of women, such as childcare and transportation. 

• Have a strong female presence on staff. 

• Promote bonding among women. 

In addition, the consensus panel adds the following advice: 

• Offer program components that help women reduce the stress associated with parenting, and 

teach parenting skills. 

• Develop programs for both women and children. 

• Provide interventions that focus on trauma and abuse. 

• Foster family reintegration and build positive ties with the extended/kinship family. 

• Build healthy support networks with shared family goals. 

• Make prevention and emotional support programs available for children. 

210 Special Settings and Specific Populations 
The Triad Women’s Project: A Cooperative Agreement 

Network 

Overview 

The Triad Women’s Project was developed in 1998 with funds from a SAMHSA collaborative grant on Women, 

Co-Occurring Disorders, and Violence. The project was designed to provide integrated services for women with 

histories of trauma and abuse who have COD. Clients were frequent users of mental health and substance abuse 

treatment services in a semirural area of Florida that spans three counties. Services in the area previously had 

been delivered by different agencies in a nonintegrated system. 

Clients 

The program served up to 175 women, many of whom were mandated to treatment by the court. 

Services 

The three main service components were 

•Triad Specialists. The Triad Specialists who provided case management services were located in and funded by their respective mental health or substance abuse treatment programs. They were cross-trained in 

mental health, substance abuse, and trauma/violence/abuse issues. (A cross-training package was developed on a video that features 16 hours of instruction.) The Triad Specialists met regularly to share information and resources. Caseloads were restricted to 25 clients, all of whom had histories of abuse and were 

diagnosed with COD. The Triad Specialist became a woman’s case manager at the client’s entrance into 

the “gateway” agency. The specialist continued to work with her even if she used other services. 

•Triad Women’s Group. This component was developed to assist triply diagnosed women with their substance abuse, mental health, and trauma issues. This integrated intervention was designed as a 16-week 

therapy group, employing a manualized skill development curriculum that could be used in outpatient or 

residential settings. 

•Peer Support Group. The peer support group, called Women of Wisdom, was run by consumers/survivors 

and served both as a support group for women in treatment and as a continuing support group for those 

who had left. The groups were based on a 12-Step model for trauma survivors, but addressed substance 

abuse and mental health recovery issues. They met in community settings and were open to all women in 

the community. 

Preliminary Empirical Evidence 

A formal evaluation of the project began in October 2000. Data have shown reductions in mental disorder 

symptoms, reductions in symptoms related to child sexual abuse, and improvements in “approach or active” 

coping responses related to substance abuse recovery (as measured by the Coping Responses Inventory 

[Moos 1993]) as a result of the group intervention. 

its, decreases in high-risk behavior, and 

enhanced overall functioning. 

The Triad Women’s Project 

This project, featured in the text box above, 

has found, consistent with the Diagnostic and 

Statistical Manual of Mental Disorders, 4th 

edition, that the prevalence of depression and 

anxiety disorders, especially PTSD, is higher 

among women than men, and that the incidence of borderline personality disorder also 

is higher (APA 2000). 

Need for increased empirical 

information 

Knowledge about, and understanding of, 

women with COD needs to be expanded, particularly for those women who experience 

Special Settings and Specific Populations 211 
SMI. The knowledge base should include 

accurate information on the rates of incidence 

of COD among women who have SMI, their 

profiles, and their use of services. In addition, COD outcome studies need to focus on 

gender differences to further improve treatment protocols for women. Research efforts 

should address the following questions: 

•Medication—Do the problems that women in 

general have with prescribed psychoactive 

medication (e.g., concerns about weight gain 

affecting adherence) hold for women with 

COD, especially those who have SMI? 

•HIV/AIDS risk—Is the current popularity 

of heroin or methamphetamine translating 

to increased HIV/AIDS in this subpopulation of women? Are there increasing rates of 

transmission of HIV/AIDS among females 

who abuse substances? 

•Populations—What differences exist among 

different populations (e.g. women, teens, 

lesbian/gay/bisexual, rural, older adults)? 

•Drug use—Is the current decline in crack 

cocaine use reflected in the drug habits of 

these women? 

•Networks—Do social networks of women 

with COD support recovery, or do they trigger relapse? 

•Trauma—Does the severity of mental illness 

affect the experience of trauma, violence, 

and victimization? What are the effects of 

trauma, violence, and abuse on the course 

of treatment for women with COD? 

•Systems—Do existing models meet the complicated service needs of women with COD? 

Do these models achieve effective linkages 

with supports based in the community? Do 

these structures support women with SMI? 

•Community connections—How are linkages 

established and maintained? 

•Treatment—What treatment components 

are effective for women with COD, particularly those who have severe mental disorders? 

•Outcomes—Are various treatments differentially effective for women? How do existing strategies and models for the treatment 

of COD need to be modified to produce the 

best outcomes for women? (Adapted from 

Alexander 1996) 

212 Special Settings and Specific Populations 
8 A Brief Overview of 

Specific Mental 

Disorders and CrossIn This Cutting Issues Chapter... 

Cross-Cutting



Issues



Personality



Disorders



Mood Disorders



and Anxiety



Disorders



Schizophrenia and



Other Psychotic



Disorders



Attention-Deficit/



Hyperactivity



Disorder (AD/HD)



Posttraumatic



Stress Disorder



(PTSD)



Eating Disorders



Pathological



Gambling



Conclusion



Overview 

This chapter provides a brief overview for working with substance 

abuse treatment clients who also have specific mental disorders. It is 

presented in concise form so that the counselor can refer to this one 

chapter to obtain basic information. Appendix D contains more indepth information on suicidality, nicotine dependence, and each of the 

disorders addressed in this chapter. The material included is not a 

complete review of all disorders in the Diagnostic and Statistical 

Manual of Mental Disorders, 4th edition (DSM-IV), but updates the 

material from TIP 9 (Center for Substance Abuse Treatment 1994a) 

(i.e., personality disorders, mood disorders, anxiety disorders, and 

psychotic disorders), adding other mental disorders with special relevance to co-occurring disorders (COD) not covered in TIP 9 (i.e., 

attention deficit/hyperactivity disorder, posttraumatic stress disorder, 

eating disorders, and pathological gambling). The consensus panel 

acknowledges that people with COD may have multiple combinations 

of the various mental disorders presented in this chapter (e.g., a person with a substance use disorder, schizophrenia, and a pathological 

gambling problem). However, for purposes of clarity and brevity the 

panel chose to focus the discussion on the main disorders and not 

explore the multitude of possible combinations. 

The chapter begins with a brief description of cross-cutting issues— 

suicidality and nicotine dependency. While suicidality is not a DSM-IV 

diagnosed mental disorder per se, it is a high-risk behavior associated 

with COD. Nicotine dependency is recognized as a disorder in DSMIV, and as such a client with nicotine dependency and a mental disorder could be considered to have a co-occurring disorder. Though this 

is the case, an important difference between tobacco addiction and 

213 
other addictions is that tobacco’s chief effects 

are medical rather than behavioral, and, as 

such, it is not conceptualized and presented 

as a typical co-occurring addiction disorder. 

However, because of the high proportion of 

the COD population addicted to nicotine, as 

well as the devastating health consequences of 

tobacco use, nicotine dependency is treated as 

an important cross-cutting issue for people 

with substance use disorders and mental illness. 

The discussions of suicidality and nicotine 

dependency highlight key information counselors should know about that disorder in 

combination with substance abuse. This section offers factual information (e.g., prevalence data), commonly agreed-upon clinical 

practices, and other general information that 

may be best characterized as “working formulations.” 

A brief description of selected disorders and 

their diagnostic criteria follows. This material 

has been extracted from DSM-IV-TR (Text 

Revision, American Psychiatric Association 

[APA] 2000) and highlights the descriptive 

features, diagnostic features, and symptom 

clusters of each mental disorder. The consensus panel elected to take this material directly 

from DSM-IV-TR to provide easy access to 

the material that is not typically available in 

the substance abuse treatment field. Use of a 

specialized dictionary that includes terminology related to mental disorders may be needed to understand terms in the quoted material 

from DSM-IV-TR, though the main features 

of each disorder should still be clear. 

Because of the greater availability of case histories from the mental health literature, the 

illustrative material in the next section has a 

greater emphasis on the mental disorder. 

Wherever possible case histories were selected 

to illustrate the interaction of the mental and 

substance use disorders. Finally, each section 

contains an Advice to the Counselor box. 

The consensus panel recognizes that no one 

chapter can replace the comprehensive training necessary for diagnosing and treating 

clients with specific mental disorders cooccurring with substance use disorders and 

that the Advice to the Counselor understates 

the complexity involved in treating clients 

with these disorders. The Advice to the 

Counselor boxes are designed to distill for the 

counselor the main actions and approaches 

that they can take in working with substance 

abuse treatment clients who have the specific 

mental disorder being discussed (see the table 

of contents for a full listing of these boxes 

throughout the TIP). 

The consensus panel also recognizes the chapter cannot possibly cover each mental disorder exhaustively and that addiction counselors are not expected to diagnose mental 

disorders. The limited goals of the panel in 

providing this material are to increase substance abuse treatment counselors’ familiarity 

with mental disorders terminology and criteria, as well as to provide advice on how to 

proceed with clients who demonstrate these 

disorders. It is also the purpose of this chapter and appendix D to stimulate further work 

in this area and to make this research accessible to the addiction field. 

Cross-Cutting Issues 

Suicidality 

Suicidality is not a mental disorder in and of 

itself, but rather a high-risk behavior associated with COD, especially (though not limited 

to) serious mood disorders. Research shows 

that most people who kill themselves have a 

diagnosable mental or substance use disorder 

or both, and that the majority of them have 

depressive illness. Studies indicate that the 

most promising way to prevent suicide and 

suicidal behavior is through the early recognition and treatment of substance abuse and 

mental illnesses. This is especially true of 

clients who have serious depression (U.S. 

Public Health Service 1999). Substanceinduced or exacerbated suicidal ideations, 

intentions, and behaviors are an ever-present 

214 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
possible complication of substance use disorders, especially 

for clients with co-occurring 

mental disorders. 

The topic of suicidality is critical 

for substance abuse treatment 

counselors working with clients 

with COD. Substance use disorders alone increase suicidality, 

while the added presence of some 

mental disorders doubles an 

already heightened risk. 

Counselors should be aware that 

the risk of suicide is greatest 

when relapse occurs after a substantial period of abstinence— 

especially if there is concurrent 

financial or psychosocial loss. 

Every agency that offers counseling for substance abuse also 

must have a clear protocol in 

place that addresses the recognition and treatment (or referral) 

of persons who may be suicidal. 

What counselors 

should know about 

suicide and 

substance abuse 

Counselors should be aware of the 

following facts about the association between suicide and substance abuse: 

•Abuse of alcohol or drugs is a 

major risk factor in suicide, both for people 

with COD and for the general population. 

•Alcohol abuse is associated with 25 to 50 percent of suicides. Between 5 and 27 percent of 

all deaths of people who abuse alcohol are 

caused by suicide, with the lifetime risk for 

suicide among people who abuse alcohol estimated to be 15 percent. 

•There is a particularly strong relationship 

between substance abuse and suicide among 

young people. 

Advice to the Counselor: 

Counseling a Client Who Is Suicidal 

• Screen for suicidal thoughts or plans with anyone who 

makes suicidal references, appears seriously depressed, or 

who has a history of suicide attempts. Treat all suicide 

threats with seriousness. 

• Assess the client’s risk of self-harm by asking about what 

is wrong, why now, whether specific plans have been 

made to commit suicide, past attempts, current feelings, 

and protective factors. (See the discussion of suicidality in 

appendix D for a model risk assessment protocol.) 

• Develop a safety and risk management process with the 

client that involves a commitment on the client’s part to 

follow advice, remove the means to commit suicide (e.g., 

a gun), and agree to seek help and treatment. Avoid sole 

reliance on “no suicide contracts.” 

• Assess the client’s risk of harm to others. 

• Provide availability of contact 24 hours per day until psychiatric referral can be realized. Refer those clients with 

a serious plan, previous attempt, or serious mental illness 

for psychiatric intervention or obtain the assistance of a 

psychiatric consultant for the management of these 

clients. 

• Monitor and develop strategies to ensure medication 

adherence. 

• Develop long-term recovery plans to treat substance 

abuse. 

• Review all such situations with the supervisor and/or 

treatment team members. 

• Document thoroughly all client reports and counselor 

suggestions. 

• Comorbidity of alcoholism and depression 

increases suicide risk. 

• The association between alcohol use and suicide also may relate to the capacity of alcohol 

to remove inhibitions, leading to poor judgment, mood instability, and impulsiveness. 

• Substance intoxication is associated with 

increased violence, both toward others and 

self. 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 215 
Case study: counseling a substance abuse treatment 

client who is suicidal 

Beth M., an American-Indian woman, comes 

to the substance abuse treatment center complaining that drinking too much causes problems for her. She has tried to stop drinking 

before but always relapses. The counselor 

finds that she is not sleeping, has been eating 

poorly, and has been calling in sick to work. 

She spends much of the day crying and thinking of how alcohol, 

which has cost her 

her latest significant relationship, 

has ruined her life. 

She also has been 

taking painkillers 

for a recurring 

back problem, 

which has added to

her problems. The 

counselor tells her

about a group 

therapy opportunity at the center 

that seems right for

her, tells her how 

to register, and 

makes arrangements for some 

individual counseling to set her on 

the right path. The 

counselor tells her 

she has done the 

right thing by coming in for help and gives 

her encouragement about her ability to stop 

drinking. 

Beth M. does not arrive for her next appointment, and when the counselor calls home, he 

learns from her roommate that Beth made an 

attempt on her life after leaving the substance 

abuse treatment center. She took an overdose 

of opioids (painkillers) and is recovering in 

the hospital. The emergency room staff found 

that Beth M. was under the influence of alcohol when she took the opioids. 

Discussion: Although Beth M. provided 

information that showed she was depressed, 

the counselor did not explore the possibility 

of suicidal thinking. Counselors always 

should ask if the client has been thinking of 

suicide, whether or not the client mentions 

depression. An American-Indian client, in 

particular, may not answer a very direct 

question, or may hint at something darker 

without mentioning it directly. Interpreting 

the client’s response requires sensitivity on 

the part of the counselor. It is important to 

realize that such questions do not increase the 

likelihood of suicide. Clients who, in fact, are 

contemplating suicide are more likely to feel 

relieved that the subject has now been 

brought into the light and can be addressed 

with help from someone who cares. 

It is important to note that the client reports 

taking alcohol and pain medications. Alcohol 

impairs judgment and, like pain medications, 

depresses brain and body functions. The 

combination of substances increases the risk 

of suicide or accidental overdose. Readers are 

encouraged to think through this case and 

apply the assessment strategy included in the 

discussion of suicidality in appendix D, imagining what kind of answers the counselor 

might have received. Then, readers could 

consider interventions and referrals that 

would have been possible in their treatment 

settings. 

Counselors 

always should 

ask if the client		

has been 

thinking of 

suicide, whether 

or not the client 

mentions 

depression.		

Nicotine Dependence 

In 2003 an estimated 29.8 percent of the general population aged 12 or older report current (past month) use of a tobacco product 

(National Survey on Drug Use and Health 

2003c). The latest report of the Surgeon 

General on the Health Consequences of 

Smoking (U.S. Public Health Service Office 

of the Surgeon General 2004) provides a 

startling picture of the damage caused by 

tobacco. Tobacco smoking injures almost 

every organ in the body, causes many dis216 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
eases, reduces health in general, and leads to 

reduced life span and death. Tobacco dependence also has serious consequences to nonsmokers through environmental tobacco 

smoke (secondhand smoke) and the negative 

effects on unborn children. Fortunately quitting smoking has immediate as well as longterm benefits (U.S. Public Health Service 

Office of the Surgeon General 2004). 

Evidence suggests that people with mental disorders and/or dependency on other drugs are 

more likely to have a tobacco addiction. In 

fact, most people with a mental illness or 

another addiction are tobacco dependent— 

about 50 to 95 percent, depending on the subgroup (Anthony and Echeagaray-Wagner 

2000; Centers for Disease Control and 

Prevention 2001; National Institute on Drug 

Abuse 1999a; Richter 2001; Stark and 

Campbell 1993b). Smokers with mental disorders consume nearly half of all the cigarettes 

sold in the United States (Lasser et al. 2000). 

A study of individuals doing well in recovery 

from alcohol dependence found that those 

who smoked lived 12 fewer years because of 

their tobacco dependence and the quality of 

their lives was affected by other tobaccocaused medical illnesses (Hurt et al. 1996). 

There is increasing recognition of the importance of integrating tobacco dependence 

treatment and management into mental health 

services and addiction treatment settings. 

Although tobacco dependence treatment 

works for smokers with mental illness and 

other addictions, only recently have clinicians 

been given training to address this serious 

public health and addiction treatment concern. It is increasingly recognized that all 

clients deserve access to effective treatments 

for tobacco addiction, and that smokers and 

their families should be educated about the 

considerable risks of smoking as well as the 

benefits of tobacco dependence treatment. All 

current tobacco dependence clinical practice 

guidelines strongly recommend addressing 

tobacco during any clinical contact with 

smokers and suggest the use of one or more of 

the six Food and Drug Administration (FDA)­

approved medications as first-line treatments 

(e.g., bupropion SR/zyban and the nicotine 

patch, gum, nasal spray, inhaler, and 

lozenge). 

Tobacco use and dependence should be 

assessed and documented in all clinical baseline assessments, treatment plans, and treatment efforts. A motivation-based treatment 

model allows for a wider range of treatment 

goals and interventions that match the 

patient’s motivation to change. Like other 

addictions, tobacco dependence is a chronic 

disease that may require multiple treatment 

attempts for many individuals and there is a 

range of effective clinical interventions, 

including medications, patient/family education, and stage-based psychosocial treatments. Recent evidence-based treatment 

guidelines have been published for the management of tobacco dependence and this 

information can be a primary guide for 

addressing tobacco. Few recognize how ignoring tobacco perpetuates the stigma associated 

with mental illness and addiction when some 

ask, “Why should tobacco be addressed in 

mental health or addiction settings?” or 

“Other than increased morbidity and mortality, why should we encourage and help this 

group to quit?” or “What else are they going 

to do if they cannot smoke?” 

What counselors should 

know about nicotine 

dependence 

• Tobacco dependence is common in clients 

with other substance use disorders and mental illnesses. 

•Like patients in primary care settings, 

clients in mental health services and addiction treatment settings should be screened 

for tobacco use and encouraged to quit. 

•The U.S. Public Health Service Guidelines 

encourage the use of the “5 A’s” (Ask, 

Advise, Assess, Assist, Arrange Followup) 

as an easy road map to guide clinicians to 

help their patients who smoke: 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 217 
–		

–		

–		

–		

–		

Ask about tobacco use and document in 

chart. 

Advise to quit in a clear, strong, and
 


personal message.



Assess willingness to make a quit 

attempt and consider motivational interventions for the lower motivated and 

assist those ready to quit. 

Assist in a quit attempt by providing 

practical counseling, setting a quit date, 

helping them to anticipate the challenges 

they will face, recommending the use of 

tobacco dependence treatment medications, and discussing options for psychosocial treatment, including individual, group, telephone, and Internet counseling options. 

Arrange followup to enhance motivation, support success, manage relapses, 

and assess medication use and the need 

for more intensive treatment if necessary. 

•Assessment of tobacco use includes assessing 

the amount and type of tobacco products 

used (cigarettes, cigars, chew, snuff, etc.), 

current motivation to quit, prior quit 

attempts (what treatment, how long abstinent, and why relapsed), withdrawal symptoms, common triggers, social supports and 

barriers, and preference for treatment. 

•Behavioral health professionals already 

have many of the skills necessary to provide 

tobacco dependence psychosocial interventions. 

•Smokers with mental illness and/or another 

addiction can quit with basic tobacco 

dependence treatment, but may also 

require motivational interventions and 

treatment approaches that integrate medications and psychosocial treatments. 

•Tobacco treatment is cost-effective, feasible, 

and draws on principles of addictions and 

co-occurring disorders treatment. 

•The current U.S. Clinical Practice 

Guidelines indicate that all patients trying 

to quit smoking should use first-line pharmacotherapy, except in cases where there 

may be contraindications (Fiore 2000). 

•Currently there are six FDA-approved 

treatments for tobacco dependence treatment: bupropion SR and five Nicotine 

Replacement Treatments (NRTs): nicotine 

polacrilex (gum), nicotine transdermal 

patch, nicotine inhaler, nicotine nasal 

spray, and nicotine lozenge. 

•Tobacco treatment medications are effective 

even in the absence of psychosocial treatments, but adding psychosocial treatments 

to medications enhances outcomes by at 

least 50 percent. 

•Specific coping skills should be addressed to 

help smokers with mental or substance use 

disorders to cope with cravings associated 

with smoking cues in treatment settings 

where smoking is likely to be ubiquitous. 

•When clients with serious mental illnesses 

attempt to quit smoking, watch for changes 

in mental status, medication side effects, 

and the need to lower some psychiatric 

medication dosages due to tobacco smoke 

interaction. 

Program-level changes 

As with other COD, the most effective strategies to address tobacco include both enhancing clinician skills and making program and 

system changes. Effective steps for addressing 

tobacco at the treatment program level are 

listed in an outline in the text box on page 

219. These steps have been developed at the 

University of Medicine and Dentistry of New 

Jersey Tobacco Program and used effectively 

to address tobacco in hundreds of mental 

health and addiction treatment settings 

(Ziedonis and Williams 2003a). The necessary 

steps include developing comprehensive 

tobacco dependence assessments; providing 

218 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
Steps for Addressing Tobacco Within Treatment Programs 

Source: Ziedonis et al. 2003. 

1. Acknowledge the challenge. 

2. Establish a leadership group and commit to change. 

3. Create a change plan and implementation timeline. 

4. Start with easy system changes. 

5. Assess and document in charts nicotine use, dependence, and prior treatments. 

6. Incorporate tobacco issues into client education curriculum. 

7. Provide medications for nicotine dependence treatment and required abstinence. 

8. Conduct staff training. 

9. Provide treatment and recovery assistance for interested nicotine-dependent staff. 

10. Integrate motivation-based treatments throughout the system. 

11. Develop addressing tobacco policies that are site specific. 

12. Establish ongoing communication with 12-Step recovery groups, professional colleagues, and referral 

sources about system changes. 

treatment, patient education, and continuing 

care planning; making self-help groups such 

as Nicotine Anonymous available to clients 

and their families; providing nicotine dependence treatment to interested staff; and making policy changes related to tobacco. Such 

changes should include documentation forms 

in clinical charts that contain more tobacco 

related questions, labeling smoker’s charts, 

not referring to breaks in the program’s 

schedule as “smoking breaks,” forbidding 

staff and patients to smoke together, providing patient education brochures, and providing NRT for all clients in smoke-free residential treatment settings (Ziedonis and Williams 

2003a). 

Case study: addressing tobacco in an individual with 

panic disorder and alcohol 

dependence 

Tammy T. is a 47-year-old widow who has 

been treated in a substance abuse outpatient 

program for co-occurring alcohol dependence 

and panic disorder. She is about 9 months 

abstinent from alcohol and states that she is 

now ready to address her tobacco addiction. 

When she first entered treatment she was not 

ready to quit tobacco. Her substance abuse 

counselor recognized her ambivalence and 

implemented some motivational interventions 

and followup on this topic over the course of 

the 9 months of her initial recovery. This persistence was perceived as expressing empathy 

and concern, and Tammy T. eventually recognized the need to quit smoking as part of a 

long-term recovery plan. She was now ready 

to set a quit date. 

Tammy T. started smoking at age 17. Her 

only period of abstinence was during her 

pregnancy. She quickly resumed smoking 

after giving birth. She cut back from 30 

cigarettes per day (1.5 packs) to 20 cigarettes 

per day (1 pack) in the last year but has been 

unable to quit completely. She lives with her 

brother, who also smokes. Her panic disorder 

is well controlled by sertraline (Zoloft), and 

she sees a counselor monthly and a psychiatrist four times a year for medication management. She works full time in a medical office 

as an office manager and must leave the 

building to smoke during work hours. Tammy 

T. drank alcohol heavily for many years, consuming up to 10 beers 3 to 5 times per week 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 219 
until about 1 year ago. At the advice of her 

physician, who initiated treatment for panic 

attacks, she was able to quit using alcohol 

completely. She was encouraged by her success in stopping drinking, but has been discouraged about continuing to smoke. 

In creating a quit plan for Tammy T., it was 

important for the counselor to determine 

what supports she has available to help her to 

quit. Encouraging her brother to quit at the 

same time was seen as a useful strategy, as it 

would help to remove smoking from the home 

environment. Tammy T. was willing to attend 

a 10-week group treatment intervention to get 

additional support, education, and assistance 

with quitting. Some clients may desire individual treatment that is integrated into their 

ongoing mental health or addiction treatment, 

or the use of a telephone counseling service 

might be explored since it is convenient and is 

becoming more widely available. In discussing 

medication options, Tammy T. indicated that 

she was willing to use the nicotine inhaler. 

Medication education enhanced compliance 

with the product and increased its effectiveness. She was encouraged to set a quit date 

and to use nicotine replacement starting at 

the quit date and in an adequate dose. 

Tammy T. was taking sertraline for her panic 

disorder (a selective serotonin reuptake 

inhibitor [SSRI]) and therefore another medication option might be to add bupropion SR 

(not an SSRI) to her current medications for 

a period of 12 weeks, specifically to address 

smoking if another quit attempt is needed in 

the future. If she had not been successful in 

this attempt, it would have been important to 

motivate her for future quit attempts and 

consider increasing the dose and/or duration 

of the medication or psychosocial treatment. 

In this case the group treatment, 6 months of 

NRT inhaler, and eliciting her brother’s 

agreement to refrain from smoking in the 

house resulted in a successful quit attempt, as 

well as continued success in her recovery 

from co-occurring panic disorder and alcohol 

dependence. 

Personality Disorders 

These are the disorders seen most commonly by 

addiction counselors and in quadrant II substance abuse treatment settings. 

Personality disorders (PDs) are rigid, inflexible, and maladaptive behavior patterns of 

sufficient severity to cause internal distress or 

significant impairment in functioning. PDs 

are enduring and persistent styles of behavior 

and thought, rather than rare or unusual 

events in someone’s life. Furthermore, rather 

than showing these thoughts and behaviors in 

response to a particular set of circumstances 

or particular stressors, people with PDs 

carry with them these destructive patterns of 

thinking, feeling, and behaving as their way 

of being and interacting with the world and 

others. 

Those who have PDs tend to have difficulty 

forming a genuinely positive therapeutic 

alliance. They tend to frame reality in terms 

of their own needs and perceptions and not to 

understand the perspectives of others. Also, 

most clients with PDs tend to be limited in 

terms of their ability to receive, accept, or 

benefit from corrective feedback. 

A further difficulty is the strong countertransference clinicians can have in working 

with these clients, who are adept at “pulling 

others’ chains” in a variety of ways. Specific 

concerns will, however, vary according to the 

specific PD and other individual circumstances. 

Borderline Personality 

Disorder 

What counselors should 

know about substance abuse 

and borderline personality 

disorders 

The essential feature of borderline personality 

disorder (BPD) is a pervasive pattern of instability of interpersonal relationships, self-image, 

and affects, along with marked impulsivity, 

220 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
Diagnostic Features of Personality Disorders 

The essential feature of a personality disorder is an enduring pattern of inner experience and behavior that 

deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the 

following areas: cognition, affectivity, interpersonal functioning, or impulse control (Criterion A). This 

enduring pattern is inflexible and pervasive across a broad range of personal and social situations 

(Criterion B) and leads to clinically significant distress or impairment in social, occupational, or other 

important areas of functioning (Criterion C). The pattern is stable and of long duration, and its onset can 

be traced back at least to adolescence or early adulthood (Criterion D). The pattern is not better accounted 

for as a manifestation or consequence of another mental disorder (Criterion E) and is not due to the direct 

physiological effects of a substance (e.g., a drug of abuse, a medication, exposure to a toxin) or a general 

medical condition (e.g., head trauma) (Criterion F). 

General diagnostic criteria for a personality disorder 

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the 

individual’s culture. This pattern is manifested in two (or more) of the following areas: 

(1) Cognition (i.e., ways of perceiving and interpreting self, other people, and events) 

(2) Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response) 

(3) Interpersonal functioning 

(4) Impulse control 

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. 

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other 

important areas of functioning. 

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early 

adulthood. 

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. 

F.	 	The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a 

medication) or a general medical condition (e.g., head trauma). 

that begins by early adulthood and is present 

in a variety of contexts. Counselors should be 

aware that 

•People with BPD may use drugs in a variety 

of ways and settings. 

•At the beginning of a crisis episode, a client 

with this disorder might take a drink or a different drug in an attempt to quell the growing 

sense of tension or loss of control. 

•People with BPD may well use the same 

drugs of choice, route of administration, and 

frequency as the individuals with whom they 

are interacting. 

• People with BPD often use substances in 

idiosyncratic and unpredictable patterns. 

• Polydrug use is common, which may involve 

alcohol and other sedative-hypnotics taken 

for self-medication. 

• Individuals with BPD often are skilled in 

seeking multiple sources of medication that 

they favor, such as benzodiazepines. Once 

they are prescribed this medication in a mental health system, they may demand to be 

continued on the medication to avoid dangerous withdrawal. 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 221 
Case Study: Counseling a 

Substance Abuse Treatment 

Client With Borderline 

Personality Disorder 

Ming L., an Asian female, was 32 years old 

when she was taken by ambulance to the local 

hospital’s emergency room. Ming L. had 

taken 80 Tylenol capsules and an unknown 

amount of Ativan in a suicide attempt. Once 

medically stable, Ming L. was evaluated by 

the hospital’s social worker to determine her 

clinical needs. 

The social worker asked Ming L. about her 

family of origin. Ming L. gave a cold stare 

and said, “I don’t talk about that.” Asked if 

she had ever been sexually abused, Ming L. 

replied, “I don’t remember.” Ming L. 

acknowledged previous suicide attempts as 

well as a history of cutting her arm with a 

razor blade during stressful episodes. She 

reported that the cutting “helps the pain.” 

Ming L. denied having “a problem” with substances but admitted taking “medication” and 

“drinking socially.” A review of Ming L.’s 

Advice to the Counselor: 

Counseling a Client With Borderline 

Personality Disorder 

• Anticipate that client progress will be slow and uneven. 

• Assess the risk of self-harm by asking about what is 

wrong, why now, whether the client has specific plans 

for suicide, past attempts, current feelings, and protective factors. (See the discussion of suicidality in appendix 

D for a risk assessment protocol.) 

• Maintain a positive but neutral professional relationship, 

avoid overinvolvement in the client’s perceptions, and 

monitor the counseling process frequently with supervisors and colleagues. 

• Set clear boundaries and expectations regarding limits 

and requirements in roles and behavior. 

• Assist the client in developing skills (e.g., deep breathing, 

meditation, cognitive restructuring) to manage negative 

memories and emotions. 

medications revealed the use of Ativan “when 

I need it.” It soon became clear that Ming L. 

was using a variety of benzodiazepines (antianxiety medications) prescribed by several 

doctors and probably was taking a daily dose 

indicative of serious dependence. She reported using alcohol “on weekends with friends” 

but was vague about the amount. Ming L. did 

acknowledge that before her suicide attempts, 

she drank alone in her apartment. This last 

suicide attempt was a response to a breakup 

with her boyfriend. Ming L.’s insurance company is pushing for immediate discharge and 

has referred her to the substance abuse treatment counselor to “address the addictions 

problem.” 

The counselor reads through notes from an 

evaluating psychiatrist and reviews the social 

worker’s report of his interview with Ming. 

She notes that the psychiatrist describes the 

client as having a severe borderline personality disorder, major recurrent depression, and 

dependence on both benzodiazepines and 

alcohol. The counselor advises the insurance 

company that unless the client’s co-occurring 

disorders also are addressed, there is little 

that substance abuse treatment 

counseling will be able to accomplish. 

Discussion: While it is important not to refuse treatment for 

clients with co-occurring disorders, it is also important to 

know the limits of what a substance abuse treatment counselor or agency can and cannot 

do realistically. A client with 

problems this serious is unlikely 

to do well in standard substance 

abuse treatment unless she also 

is enrolled in a program qualified to provide treatment to 

clients with borderline personality disorders, and preferably in 

a program that offers treatment 

designed specially for this disorder such as Dialectical Behavior 

Therapy (Linehan et al. 1999) 

222 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
Diagnostic Features of Borderline Personality Disorder 

Source: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 706–708, 710). 

The essential feature of borderline personality disorder is a pervasive pattern of instability of interpersonal 

relationships, self-image, and affects, along with marked impulsivity that begins by early adulthood and is 

present in a variety of contexts. Individuals with borderline personality disorder make frantic efforts to 

avoid real or imagined abandonment (Criterion 1). Individuals with borderline personality disorder have a 

pattern of unstable and intense relationships (Criterion 2). There may be an identity disturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3). Individuals with this disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4). Individuals 

with borderline personality disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (Criterion 5). Individuals with borderline personality disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety 

usually lasting a few hours and only rarely more than a few days) (Criterion 6). Individuals with borderline 

personality disorder may be troubled by chronic feelings of emptiness (Criterion 7). Individuals with borderline personality disorder frequently express inappropriate, intense anger or have difficulty controlling 

their anger (Criterion 8). During periods of extreme stress, transient paranoid ideation or dissociative 

symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity 

or duration to warrant an additional 

diagnosis. 

Diagnostic criteria for borderline personality disorder 

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity 

beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: 

(1)		 Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating 

behavior covered in Criterion 5. 

(2)		 A pattern of unstable and intense interpersonal relationships characterized by alternating between 

extremes of idealization and devaluation. 

(3)		 Identity disturbance: markedly and persistently unstable self-image or sense of self. 

(4)		 Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, 

reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in 

Criterion 5. 

(5)		 Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 

(6)		 Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or 

anxiety usually lasting a few hours and only rarely more than a few days). 

(7)		 Chronic feelings of emptiness. 

(8)		 Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant 

anger, recurrent physical fights). 

(9)		 Transient, stress-related paranoid ideation or severe dissociative symptoms. 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 223 
(although substance abuse treatment programs are increasingly developing their 

capacities to address specialized mental disorders). She is likely to need complicated detoxification either on an inpatient basis or in a 

long-term outpatient program that knows how 

to enclose the kinds of behavioral chaos that 

borderline clients often experience. 

Antisocial Personality 

Disorder 

The two essential features of antisocial personality disorder (APD) are: (1) a pervasive disregard for and violation of the rights of others, 

and (2) an inability to form meaningful interpersonal relationships. 

What counselors should 

know about substance abuse 

and APD 

The prevalence of antisocial personality disorder and substance abuse is high: 

•Much of substance abuse treatment is particularly targeted to those with APD, and substance abuse treatment alone has been particularly effective for these disorders. 

•The majority of people with substance use 

disorders are not sociopathic except as a 

result of their addiction. 

•Most people diagnosed as having APD are not 

true psychopaths—that is, predators who use 

manipulation, intimidation, and violence to 

control others and to satisfy their own needs. 

•Many people with APD use substances in a 

polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine. 

•People with APD may be excited by the illegal 

drug culture and may have considerable 

pride in their ability to thrive in the face of 

the dangers of that culture. They often are in 

trouble with the law. Those who are more 

effective may limit themselves to exploitative 

or manipulative behaviors that do not make 

them as vulnerable to criminal sanctions. 

Case study: counseling a 

substance abuse treatment 

client with antisocial 

personality disorder 

Mark R., a Hispanic/Latino male, was 27 years 

old when he was arrested for driving while 

intoxicated. Mark R. presented himself to the 

court counselor for evaluation of the possible 

need for substance abuse treatment. Mark R. 

was on time for the appointment and was 

slightly irritated at having to wait 20 minutes 

due to the counselor’s schedule. Mark R. was 

wearing a suit (which had seen better days) and 

was trying to present himself in a positive light. 

Mark R. denied any “problems with alcohol” 

and reported having “smoked some pot as a 

kid.” He denied any history of suicidal thinking or behavior except for a short period following his arrest. He acknowledged that he 

did have a “bit of a temper” and that he took 

pride in the ability to “kick ass and take 

names” when the situation required. Mark R. 

denied any childhood trauma and described 

his mother as a “saint.” He described his 

father as “a real jerk” and refused to give 

any other information. 

In describing the situation that preceded his 

arrest, Mark R. tended to see himself as the 

victim, using statements such as “The bartender should not have let me drink so 

much,” “I wasn’t driving that bad,” and 

“The cop had it in for me.” Mark R. tended 

to minimize his own responsibility throughout 

the interview. Mark R. had been married 

once but only briefly. His only comment 

about the marriage was, “She talked me into 

it but I got even with her.” Mark R. has no 

children and lives alone in a studio apartment. Mark R. has attended two meetings of 

Alcoholics Anonymous (AA) “a couple of 

years ago before I learned how to control my 

drinking.” 

The counselor coordinates closely with the 

parole officer and arranges several three-way 

meetings. He carefully reviews details of the 

court contract and conditions of parole and 

224 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
Diagnostic Features of Antisocial Personality Disorder 

Source: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 701, 702, 706). 

The essential feature of antisocial personality disorder is a pervasive pattern of disregard for, and violation 

of, the rights of others that begins in childhood or early adolescence and continues into adulthood. This pattern also has been referred to as psychopathy, sociopathy, or dyssocial personality disorder. Because deceit 

and manipulation are central features of antisocial personality disorder, it may be especially helpful to integrate information acquired from systematic clinical assessment with information collected from collateral 

sources. For this diagnosis to be given, the individual must be at least age 18 (Criterion B) and must have had 

a history of some symptoms of conduct disorder before age 15 (Criterion C). 

Diagnostic criteria for antisocial personality disorder 

A. There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15, as 

indicated by three (or more) of the following: 

(1) Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest 

(2) Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or 

pleasure 

(3) Impulsivity or failure to plan ahead 

(4) Irritability and aggressiveness, as indicated by repeated physical fights or assaults 

(5) Reckless disregard for safety of self or others 

(6) Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or 

honor financial obligations 

(7) Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen 

from another 

B. The individual is at least age 18. 

C. There is evidence of Conduct Disorder (see APA 2000, p. 98) with onset before age 15. 

D. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic 

Episode. 

keeps court records up to date. His work with 

Mark R. centers on clarifying expectations. 

Discussion. It is likely that Mark R. has 

antisocial personality disorder. Clients with 

this disorder usually are very hard to engage 

in individual treatment and are best managed 

through strict limits with clear consequences. 

With such an individual, it is important to 

maximize the interaction with the court, 

parole officers, or other legal limit setters. 

This enforces the limits of treatment, and 

prevents the client from criticizing and blaming one agency representative to the other. 

People with this disorder are best managed in 

group treatment that addresses both their 

substance abuse and antisocial personality 

disorder. In such groups the approach is to 

hold the clients responsible for their behavior 

and its consequences and to confront dishonest and antisocial behavior directly and firmly and stress immediate learning experiences 

that teach corrective responses. 

It is important to differentiate true antisocial 

personality from substance-related antisocial 

behavior. This can best be done by looking at 

how the person relates to others throughout 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 225 
the course of his or her life. Persons with this 

disorder will have evidence of antisocial 

behavior preceding substance use and even 

during periods of enforced abstinence. It also 

is important to recognize that people with 

substance-related antisocial behavior may be 

more likely to have major depression than 

other typical personality disorders. However, 

the type and character of depressions that 

may be experienced by those with true APD 

have been less well characterized, and their 

treatment is unclear. 

Mood Disorders and 

Anxiety Disorders 

Because of the striking similarities in understanding and serving clients with mood and 

anxiety disorders, the sections have been combined to address both disorders. (It should be 

noted, however, that two disorder types are 

separated in DSM-IV-TR [APA 2000].) 

What Counselors Should 

Know About Mood and 

Anxiety Disorders and 

Substance Abuse 

Counselors should be aware of the following: 

•Approximately one quarter of United States 

residents are likely to have some anxiety disorder during their lifetime, and the prevalence is higher among women than men. 

•About one half of individuals with a substance use disorder have an affective or anxiety disorder at some time in their lives. 

•Among women with a substance use disorder, mood disorders may be prevalent. 

Women are more likely than men to be clinically depressed and/or to have posttraumatic stress disorder. 

•Certain populations are at risk for anxiety 

and mood disorders (e.g., clients with HIV, 

clients maintained on methadone, and older 

adults). 

•Older adults may be the group at highest 

risk for combined mood disorder and substance problems. Episodes of mood disturbance generally increase in frequency with 

age. Older adults with concurrent mood 

and substance use disorders tend to have 

more mood episodes as they get older, even 

when their substance use is controlled. 

•Both substance use and discontinuance may 

be associated with depressive symptoms. 

•Acute manic symptoms may be induced or 

mimicked by intoxication with stimulants, 

steroids, hallucinogens, or polydrug combinations. 

•Withdrawal from depressants, opioids, and 

stimulants invariably includes potent anxiety symptoms. During the first months of 

sobriety, many people with substance use 

disorders may exhibit symptoms of depression that fade over time and that are related to acute withdrawal. 

•Medical problems and medications can produce symptoms of anxiety and mood disorders. About a quarter of individuals who 

have chronic or serious general medical 

conditions, such as diabetes or stroke, 

develop major depressive disorder. 

•People with co-occurring mood or anxiety 

disorders and a substance use disorder typically use a variety of drugs. 

•Though there may be some preference for 

those with depression to favor stimulation 

and those with anxieties to favor sedation, 

there appears to be considerable overlap. 

The use of alcohol, perhaps because of its 

availability and legality, is ubiquitous. 

•It is now believed that substance use is more 

often a cause of anxiety symptoms rather 

than an effort to cure these symptoms. 

•Since mood and anxiety symptoms may 

result from substance use disorders, not an 

underlying mental disorder, careful and 

continuous assessment is essential. 

226 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
Diagnostic Features of Mood Disorders 

The mood disorders are divided into the depressive disorders (“unipolar depression”), the bipolar disorders, 

and two disorders based on etiology—mood disorder due to a general medical condition and substance-induced 

mood disorder. The depressive disorders (i.e., major depressive disorder, dysthymic disorder, and depressive 

disorder not otherwise specified) are distinguished from the bipolar disorders by the fact that there is no history 

of ever having had a manic, mixed, or hypomanic episode. The bipolar disorders (i.e., bipolar I disorder, bipolar II disorder, cyclothymic disorder, and bipolar disorder not otherwise specified) involve the presence (or history) of manic episodes, mixed episodes, or hypomanic episodes, usually accompanied by the presence (or history) of major depressive episodes. 

The section below describes mood episodes (major depressive episode, manic episode) which are not diagnosed as separate entities, but serve as the building block for the mood disorder diagnoses. 

Major Depressive Episode 

Episode features 

The essential feature of a Major Depressive Episode is a period of at least 2 weeks during which there is either 

depressed mood or the loss of interest or pleasure in nearly all activities. In children and adolescents, the mood 

may be irritable rather than sad. The individual also must experience at least four additional symptoms drawn 

from a list that includes changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of 

death or suicidal ideation, plans, or attempts. To count toward a Major Depressive Episode, a symptom must 

either be newly present or must have clearly worsened compared with the person’s pre-episode status. The 

symptoms must persist for most of the day, nearly every day, for at least 2 consecutive weeks. The episode must 

be accompanied by clinically significant distress or impairment in social, occupational, or other important areas 

of functioning. For some individuals with milder episodes, functioning may appear to be normal but requires 

markedly increased effort. 

Criteria for major depressive episode 

Five (or more) of the following symptoms have been present during the same 2-week period and represent a 

change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. 

Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. 

(1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., 

feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. 

(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every 

day (as indicated by either subjective account or observation made by others). 

(3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 percent of body 

weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider 

failure to make expected weight gains. 

(4) Insomnia or hypersomnia nearly every day. 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 227 
(5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective 

feelings of restlessness or being slowed down). 

(6) Fatigue or loss of energy nearly every day. 

(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every 

day (not merely self-reproach or guilt about being sick). 

(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective 

account or as observed by others). 

(9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific 

plan, or a suicide attempt or a specific plan for committing suicide. 

B. The symptoms do not meet criteria for a Mixed Episode (see APA 2000, p. 365). 

C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important 

areas of functioning. 

D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). 

E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one; the symptoms 

persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. 

Manic Episode 

Episode features 

A Manic Episode is defined by a distinct period during which there is an abnormally and persistently elevated, expansive, or irritable mood. This period of abnormal mood must last at least 1 week (or less if hospitalization is required) (Criterion A). The mood disturbance must be accompanied by at least three additional 

symptoms from a list that includes inflated self-esteem or grandiosity, decreased need for sleep, pressure of 

speech, flight of ideas, distractibility, increased involvement in goal-directed activities or psychomotor agitation, and excessive involvement in pleasurable activities with a high potential for painful consequences. If 

the mood is irritable (rather than elevated or expansive), at least four of the above symptoms must be present (Criterion B). The symptoms do not meet criteria for a Mixed Episode, which is characterized by the 

symptoms of both a Manic Episode and a Major Depressive Episode occurring nearly every day for at least 

a 1-week period (Criterion C). The disturbance must be sufficiently severe to cause marked impairment in 

social or occupational functioning or to require hospitalization, or it is characterized by the presence of psychotic features (Criterion D). The episode must not be due to the direct physiological effects of a drug of 

abuse, a medication, other somatic treatments for depression (e.g., electroconvulsive therapy or light therapy), or toxin exposure. The episode also must not be due to the direct physiological effects of a general medical condition (e.g., multiple sclerosis, brain tumor) (Criterion E). 

Criteria for manic episodes 

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 

week (or any duration if hospitalization is necessary). 

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the 

mood is only irritable) and have been present to a significant degree: 

(1) Inflated self-esteem or grandiosity 

(2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 

228 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
(3) More talkative than usual or pressure to keep talking 

(4) Flight of ideas or subjective experience that thoughts are racing 

(5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) 

(6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 

(7) Excessive involvement in pleasurable activities that have a high potential for painful consequences 

(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) 

C. The symptoms do not meet criteria for a Mixed Episode (see APA 2000, p. 365). 

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in 

usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or 

others, or there are psychotic features. 

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism). 

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, 

electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder. 

Source: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 349, 356, 357, 362). 

Case Study: 

Counseling a 

Substance Abuse 

Treatment Client With 

Bipolar Disorder 

John W. is a 30-year-old AfricanAmerican man with diagnoses of 

bipolar disorder and alcohol 

dependence. He has a history of 

hospitalizations, both psychiatric 

and substance-related; after the 

most recent extended psychiatric 

hospitalization, he was referred 

for substance abuse treatment. He 

told the counselor he used alcohol 

to facilitate social contact, as well 

as deal with boredom, since he 

had not been able to work for 

some time. The counselor learned 

that during his early twenties, 

John W. achieved full-time 

employment and established an 

intimate relationship with a nondrinking woman; however, his 

drinking led to the loss of both. 

Advice to the Counselor: 

Counseling a Client With a Mood or 

Anxiety Disorder 

• Differentiate among the following: mood and anxiety 

disorders; commonplace expressions of anxiety and 

depression; and anxiety and depression associated with 

more serious mental illness, medical conditions and medication side effects, and substance-induced changes. 

• Although true for most counseling situations, it is especially important to maintain a calm demeanor and a 

reassuring presence with these clients. 

• Start low, go slow (that is, start “low” with general and 

nonprovocative topics and proceed gradually as clients 

become more comfortable talking about issues). 

• Monitor symptoms and respond immediately to any 

intensification of symptoms. 

• Understand the special sensitivities of phobic clients to 

social situations. 

• Gradually introduce and teach skills for participation in 

mutual self-help groups. 

• Combine addiction counseling with medication and mental health treatment. 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 229 
Diagnostic Features of Generalized Anxiety Disorder 

Source: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 472, 473, 476). 

The essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive expectation), 

occurring more days than not for a period of at least 6 months, about a number of events or activities (Criterion 

A). The individual finds it difficult to control the worry (Criterion B). The anxiety and worry are accompanied 

by at least three additional symptoms from a list that includes restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and disturbed sleep (only one additional symptom is required in children) (Criterion C). The focus of the anxiety and worry is not confined to features of another Axis I disorder 

such as having a panic attack (as in panic disorder), being embarrassed in public (as in social phobia), being 

contaminated (as in obsessive-compulsive disorder), being away from home or close relatives (as in separation 

anxiety disorder), losing weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur 

exclusively during posttraumatic stress disorder (Criterion D). Although individuals with generalized anxiety 

disorder may not always identify the worries as “excessive,” they report subjective distress due to constant 

worry, have difficulty controlling the worry, or experience related impairment in social, occupational, or other 

important areas of functioning (Criterion E). The disturbance is not due to the direct physiological effects of a 

substance (i.e., a drug of abuse, a medication, or toxin exposure) or a general medical condition and does not 

occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder 

(Criterion F). 

Diagnostic criteria for generalized anxiety disorder 

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, 

about a number of events or activities (such as work or school performance). 

B. The person finds it difficult to control the worry. 

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some 

symptoms present for more days than not for the past 6 months). Note: Only one item is required in children. 

(1) Restlessness or feeling keyed up or on edge 

(2) Being easily fatigued 

(3) Difficulty concentrating or mind going blank 

(4) Irritability 

(5) Muscle tension 

(6) Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) 

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or 

worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social 

Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives 

(as in Separation Anxiety Disorder), losing weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety 

and worry do not occur exclusively during Posttraumatic Stress Disorder. 

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

F.	 	The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood 

Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder. 

230 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
During one of his alcohol treatments, he 

developed florid manic symptoms, believing 

himself to be a prophet with the power to heal 

others. He was transferred to a closed psychiatric unit, where he eventually stabilized on a 

combination of antipsychotic medications 

(risperdal) and lithium. Since that time he 

has had two episodes of worsening psychiatric 

symptoms leading to hospitalization; each of 

these began with drinking, which then led to 

stopping his medications, then florid mania 

and psychiatric commitment. However, when 

he is taking his medications and is sober, 

John W. has a normal mental status and 

relates normally to others. Recently, following 

a series of stressors, John W. left his girlfriend, quit his job, and began using alcohol 

heavily again. He rapidly relapsed to active 

mania, did not adhere to a medication regimen, and was rehospitalized. 

At the point John W. is introduced to the substance abuse treatment counselor, his mental 

status is fairly normal; however, he warns the 

counselor that after manic episodes he tends 

to get somewhat depressed, even when he is 

taking medications. In taking an addiction 

history, the counselor finds that though John 

W. has had several periods of a year or two 

during which he was abstinent from both 

alcohol and drugs of abuse, he has never 

become involved with either ongoing alcohol 

treatment or AA meetings. John W. replies to 

his questions about this with, “Well, if I just 

take my meds and don’t drink, I’m fine. So 

why do I need those meetings?” 

Using a motivational approach, the counselor 

helps John W. analyze what has worked best 

for him in dealing with both addiction and 

mental problems, as well as what has not 

worked well for him. John W. is tired of the 

merry-go-round of his life; he certainly 

acknowledges that he has a major mental disorder, but thinks his drinking is only secondary to the mania. When the counselor 

gently points out that each of the episodes in 

which his mental disorder led to hospitalization began with an alcohol relapse, John W. 

begins to listen. In a group for clients with cooccurring disorders at the substance abuse 

treatment agency, John W. is introduced to 

another recovering manic patient with alcohol 

problems who tells his personal story and how 

he discovered that both of his problems need 

primary attention. This client agrees to be 

John W.’s temporary sponsor. The counselor 

calls John W.’s case manager, who works at 

the mental health center where John W. gets 

his medication, and describes the treatment 

plan. She then makes arrangements for a 

monthly meeting involving the counselor, case 

manager, and John W. 

Discussion: The substance abuse treatment 

counselor has taken the wise step of taking a 

detailed history and attempting to establish 

the linkage between co-occurring disorders. 

The counselor tries to appreciate the client’s 

own understanding of the relationship 

between the two. She uses motivational 

approaches to analyze what John W. did in 

his previous partially successful attempts to 

deal with the problem and helps develop connections with other recovering clients to 

increase motivation. Lastly, she is working 

closely with the case manager to ensure a 

coordinated approach to management of each 

disorder. 

Schizophrenia and 

Other Psychotic 

Disorders 

What Counselors Should 

Know About Substance Abuse 

and Psychotic Disorders 

There are different types of psychotic disorders 

or disorders that have psychotic features. 

Schizophrenia, a relatively common type of 

psychotic disorder, is featured in this section. 

Counselors should be aware of the following: 

• There is evidence of increasing use of alcohol 

and drugs by persons with schizophrenia 

(from 14 to 22 percent in the 1960s and 1970s 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 231 
Descriptive Features 

The term “psychotic” historically has received a number of different definitions, none of which has achieved 

universal acceptance. The narrowest definition of psychotic is restricted to delusions or prominent hallucinations, with the hallucinations occurring in the absence of insight into their pathological nature. A slightly 

less restrictive definition also would include prominent hallucinations that the individual realizes are hallucinatory experiences. Broader still is a definition that also includes other positive symptoms of schizophrenia (i.e., disorganized speech, or grossly disorganized or catatonic behavior). Unlike these definitions based 

on symptoms, the definition used in earlier classifications (e.g., DSM-II and ICD-9) probably was far too 

inclusive and focused on the severity of functional impairment. In that context, a mental disorder was 

termed “psychotic” if it resulted in “impairment that grossly interferes with the capacity to meet ordinary 

demands of life.” The term also has previously been defined as a “loss of ego boundaries” or a “gross 

impairment in reality testing.” 

Schizophrenia is a disorder that lasts for at least 6 months and includes at least 1 month of active-phase 

symptoms (i.e., two or more) of the following: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms. Definitions for the schizophrenia subtypes (paranoid, 

disorganized, catatonic, undifferentiated, and residual) are also included in this section. 

Diagnostic criteria for schizophrenia 

A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time 

during a 1-month period (or less if successfully treated): 

(1) Delusions 

(2) Hallucinations 

(3) Disorganized speech (e.g., frequent derailment or incoherence) 

(4) Grossly disorganized or catatonic behavior 

(5) Negative symptoms, i.e., affective flattening, alogia, or avolition 

Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice 

keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with 

each other. 

B. Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, 

one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly 

below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to 

achieve expected level of interpersonal, academic, or occupational achievement). 

C. Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must 

include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., activephase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal 

or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or 

more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual 

experiences). 

D. Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder With 

Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed 

Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have 

occurred during active-phase symptoms, their total duration has been brief relative to the duration of 

the active and residual periods. 

232 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological 

effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. 

F.		 Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another 

Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent 

delusions or hallucinations also are present for at least a month (or less if successfully treated). 

Classification of longitudinal course (can be applied only after at least 1 year has elapsed since the initial 

onset of active-phase symptoms): 

•Episodic With Interepisode Residual Symptoms (episodes are defined by the reemergence of prominent 

psychotic symptoms); also specify if: With Prominent Negative Symptoms 

•Episodic With No Interepisode Residual Symptoms 

•Continuous (prominent psychotic symptoms are present throughout the period of observation); also specify if: With Prominent Negative Symptoms 

•Single Episode In Partial Remission; also specify if: With Prominent Negative Symptoms 

•Single Episode In Full Remission 

•Other or Unspecified Pattern 

Source: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 298–302, 312–313). 

to 25 to 50 percent in the 1990s) (Fowler et 

al. 1998). 

•There is no clear pattern of drug choice 

among clients with schizophrenia. Instead, 

it is likely that whatever substances happen 

to be available or in vogue will be the substances used most typically. 

•What looks like resistance or denial may in 

reality be a manifestation of negative symptoms of schizophrenia. 

•An accurate understanding of the role of 

substance use disorders in the client’s psychosis requires a multiple-contact, longitudinal assessment. 

•Clients with a co-occurring mental disorder 

involving psychosis have a higher risk for 

self-destructive and violent behaviors. 

•Clients with a co-occurring mental disorder 

involving psychosis are particularly vulnerable to homelessness, housing instability, 

victimization, poor nutrition, and inadequate financial resources. 

•Both psychotic and substance use disorders 

tend to be chronic disorders with multiple 

relapses and remissions, supporting the 

need for long-term treatment. For clients 

with co-occurring disorders involving psychosis, a long-term approach is imperative. 

It is important that the program philosophy be 

based on a multidisciplinary team approach. 

Ideally, team members should be cross-trained, 

and there should be representatives from the 

medical, mental health, and addiction systems. 

The overall goals of long-term management 

should include (1) providing comprehensive 

and integrated services for both the mental and 

substance use disorders, and (2) doing so with 

a long-term focus that addresses biopsychosocial issues in accord with a treatment plan with 

goals specific to a client’s situation. 

Case Study: Counseling a 

Substance Abuse Treatment 

Client With Schizophrenia 

Adolfo M. is a 40-year-old Hispanic male who 

began using marijuana and alcohol when he 

was 15. He was diagnosed as having 

schizophrenia when he was 18 and began 

using cocaine at 19. Sometimes he lives with 

his sister or with temporary girlfriends; sometimes he lives on the street. He has never had 

a sustained relationship, and he has never 

held a steady job. He has few close friends. 

He wears long hair, tattoos, torn jeans, and tshirts with skulls or similar images. Although 

he has had periods of abstinence and freedom 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 233 
from hallucinations and major delusions, he 

generally has unusual views of the world that 

emerge quickly in conversation. 

Advice to the Counselor: 

Counseling a Client With a 

Psychotic Disorder 

• Obtain a working knowledge of the signs and symptoms 

of the disorder. 

• Work closely with a psychiatrist or mental health professional. 

• Expect crises associated with the mental disorder and 

have available resources (i.e., crisis intervention, psychiatric consultation) to facilitate stabilization. 

• Assist the client to obtain entitlements and other social 

services. 

• Make available psychoeducation on the psychiatric condition and use of medication. 

• Monitor medication and promote medication adherence. 

• Provide frequent breaks and shorter sessions or meetings. 

• Employ structure and support. 

• Present material in simple, concrete terms with examples 

and use multimedia methods. 

• Encourage participation in social clubs with recreational 

activities. 

• Teach the client skills for detecting early signs of relapse 

for both mental illness and substance abuse. 

• Involve family in psychoeducational groups that specifically focus on education about substance use disorders 

and psychosis; establish support groups of families and 

significant others. 

• Monitor clients for signs of substance abuse relapse and 

a return of psychotic symptoms. 

Adolfo M. has been referred to the substance 

abuse treatment counselor, who was hired by 

the mental health center to do most of the 

group and individual drug/alcohol work with 

clients. The first step the counselor takes is to 

meet with Adolfo M. and his case manager 

together. This provides a clinical linkage as 

well as a method to get the best history. The 

clinical history reveals that Adolfo M. does 

best when he is sober and on medications, but 

there are times when he will be 

sober and not adhere to a medical regimen, or when he is both 

taking medications and drinking 

(though these periods are becoming shorter in duration and less 

frequent). His case manager 

often is able to redirect him 

toward renewed sobriety and 

adherence to medications, but 

Adolfo M. and the case manager 

agree that the cycle of relapse 

and the work of pulling things 

back together is wearing them 

both out. After the meeting, the 

case manager, counselor, and 

Adolfo M. agree to meet weekly 

for a while to see what they can 

do together to increase the stable 

periods and decrease the relapse 

periods. After a month of these 

planning meetings, the following 

plan emerges. Adolfo M. will 

attend substance abuse treatment groups for persons with 

COD (run by the counselor three 

times a week at the clinic), see 

the team psychiatrist, and attend 

local dual disorder AA meetings. 

The substance abuse treatment 

group he will be joining is one 

that addresses not only addiction 

issues, but also issues with treatment follow through, life problems, ways of dealing with stress, 

and the need for social support 

for clients trying to get sober. 

When and if relapse happens, Adolfo M. will 

be accepted back without prejudice and supported in recovery and treatment of both his 

substance abuse and mental disorders; however, part of the plan is to analyze relapses 

with the group. His goal is to have as many 

sober days as possible with as many days 

adhering to a medical regimen as possible. 

Another aspect of the group is that monthly, 

90-day, 6-month, and yearly sobriety birthdays are celebrated with both AA coins and 

refreshments. Part of the employment program at the center is that clients need to have 

234 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
a minimum of 3 months of sobriety before 

they will be placed in a supported work situation, so this becomes an incentive for sobriety 

as well. 

Discussion: Substance abuse treatment 

counselors working within mental health centers should be aware of the need not only to 

work with the client, but also to form solid 

working relationships with case managers, the 

psychiatrist, and other personnel. Seeing 

clients with case managers and other team 

members is a good way to establish important 

linkages and a united view of the treatment 

plan. In Adolfo M.’s case, the counselor used 

his ties with the case manager to good effect 

and also is using relapse prevention and contingency management strategies appropriately 

(see chapter 5 for a discussion of these techniques). 

Attention Deficit/ 

Hyperactivity Disorder 

(AD/HD) 

What Counselors Should 

Know About Substance Abuse 

and AD/HD 

The essential feature of AD/HD is a persistent 

pattern of inattention and/or hyperactivityimpulsivity that is displayed more frequently 

and more serious than is observed typically in 

individuals at a comparable level of development (APA 2000). Counselors should be aware 

of the following: 

•Studies of the adult substance abuse treatment population have found AD/HD in 5 to 

25 percent of persons (Clure et al. 1999; 

King et al. 1999; Levin et al. 1998; 

Schubiner et al. 2000; Weiss et al. 1998). 

•Approximately one third of adults with 

AD/HD have histories of alcohol abuse or 

dependence, and approximately one in five 

has other drug abuse or dependence histories. 

•Adults with AD/HD have been found primarily to use alcohol, with marijuana being 

the second most common drug of abuse. 

•The history of a typical AD/HD substance 

abuse treatment client may show early 

school problems before substance abuse 

began. 

•The client may use self-medication for 

AD/HD as an excuse for drug use. 

•The most common attention problems in 

substance abuse treatment populations are 

secondary to short-term toxic effects of substances, and these should be substantially 

better with each month of sobriety. 

•The presence of AD/HD complicates the 

treatment of substance abuse, since clients 

with these COD may have more difficulty 

engaging in treatment and learning abstinence skills, be at greater risk for relapse, 

and have poorer substance use outcomes. 

Case Study: Counseling a 

Substance Abuse Treatment 

Client With AD/HD 

John R., a 29-year-old African-American 

man, is seeking treatment. He has been in 

several treatment programs but always 

dropped out after the first 4 weeks. He tells 

the counselor he dropped out because he 

would get cravings and that he just could not 

concentrate in the treatment sessions. He 

mentions the difficulty of staying focused during 3-hour intensive group sessions. A contributing factor in his quitting treatment was 

that group leaders always seemed to scold him 

for talking to others. The clinician evaluating 

him asks how John R. did in school and finds 

that he had difficulty in his classwork years 

before he started using alcohol and drugs; he 

was restless and easily distracted. He had 

been evaluated for a learning disability and 

AD/HD and took Ritalin for about 2 years (in 

the 5th and 6th grades), then stopped. He was 

not sure why, but he did terribly in school, 

eventually dropping out about the time he 

started using drugs regularly in the 8th grade. 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 235 
Diagnostic Features of AD/HD 

The essential feature of attention-deficit/hyperactivity disorder is a persistent pattern of inattention and/or 

hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in 

individuals at a comparable level of development (see Criterion A below). Some hyperactive-impulsive or 

inattentive symptoms that cause impairment must have been present before age 7, although many individuals are diagnosed after the symptoms have been present for a number of years, especially in the case of individuals with the predominantly inattentive type (Criterion B). Some impairment from the symptoms must be 

present in at least two settings (e.g., at home and at school or work) (Criterion C). There must be clear evidence of interference with developmentally appropriate social, academic, or occupational functioning 

(Criterion D). The disturbance does not occur exclusively during the course of a pervasive developmental 

disorder, schizophrenia, or other psychotic disorder and is not better accounted for by another mental disorder (e.g., a mood disorder, anxiety disorder, dissociative disorder, or personality disorder) (Criterion E). 

Diagnostic criteria for AD/HD 

A. Either (1) or (2): 

(1) Six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree 

that is maladaptive and inconsistent with developmental level:



Inattention



(a) Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or 

other activities 

(b) Often has difficulty sustaining attention in tasks or play activities 

(c) Often does not seem to listen when spoken to directly 

(d) Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in 

the workplace (not due to oppositional behavior or failure to understand instructions) 

(e) Often has difficulty organizing tasks and activities 

(f) Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such 

as schoolwork or homework) 

(g) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, 

or tools) 

(h) Is often easily distracted by extraneous stimuli 

(i) Is often forgetful in daily activities 

(2) Six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 

months to a degree that is maladaptive and inconsistent with developmental level:



Hyperactivity



(a) Often fidgets with hands or feet or squirms in seat 

(b) Often leaves seat in classroom or in other situations in which remaining seated is expected 

(c) Often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or 

adults, may be limited to subjective feelings of restlessness) 

(d) Often has difficulty playing or engaging in leisure activities quietly; is often “on the go” or often 

acts as if “driven by a motor” 

(e) Often talks excessively 

Impulsivity 

(a) Often blurts out answers before questions have been completed 

(b) Often has difficulty awaiting turn 

(c) Often interrupts or intrudes on others (e.g., butts into conversations or games) 

236 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
B. Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7. 

C. Some impairment from the symptoms is present in two or more settings (e.g., at school or work and at 

home). 

D. There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning. 

E. The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, 

Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder 

(e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). 

Code based on type: 

• Attention-Deficit/Hyperactivity Disorder, Combined Type: if both Criteria A1 and A2 are met for the 

past 6 months 

• Attention-Deficit/Hyperactivity Disorder, Predominantly Hyperactive-Impulsive Type: if Criterion A2 

is met but Criterion A1 is not met for the past 6 months 

Coding note: For individuals (especially adolescents and adults) who currently have symptoms that no 

longer meet full criteria, “In Partial Remission” should be specified. 

Source: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 85–87, 92–93). 

Discussion: The substance abuse treatment 

clinician reviewed John R.’s learning history 

and asked about anxiety or depressive disorders. The clinician referred him to the team’s 

psychiatrist, who uncovered more history 

about the AD/HD and also contacted John 

R.’s mother. When the clinician 

reviewed a list of features commonly associated with AD/HD, 

she agreed that John R. had 

many of these features and that 

she had noticed them in childhood. John R. was started on 

bupropion medication and 

moved to a less intensive level of 

care (1 hour of group therapy, 

30 minutes of individual counseling, and AA meetings three times weekly). 

Over the next 2 months, John R.’s ability to 

tolerate a more intensive treatment improved. 

Although he was still somewhat intrusive to 

others, he was able to benefit from more 

intensive group treatment. 

Advice to the Counselor: 

Counseling a Client Who Has AD/HD 

• Clarify for the client repeatedly what elements of a question he or she has responded to and what remains to be 

addressed. 

• Eliminate distracting stimuli from the environment. 

• Use visual aids to convey information. 

• Reduce the time of meetings and length of verbal 

exchanges. 

• Encourage the client to use tools (e.g., activity journals, 

written schedules, and “to do” lists) to organize important events and information. 

• Refer the client for evaluation of the need for medication. 

• Focus on enhancing the client’s knowledge about AD/HD 

and substance abuse. Examine with the client any false 

beliefs about the history of both AD/HD and substance 

abuse difficulties. 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 237 
Posttraumatic Stress 

Disorder (PTSD) 

What Counselors Should 

Know About Substance Abuse 

and PTSD 

PTSD is classified in DSM-IV-TR as one type 

of anxiety disorder. It is treated separately in 

this TIP because of its special relationship to 

substance abuse and the growing literature on 

PTSD and its treatment. 

The essential feature of PTSD is the development of characteristic symptoms following 

exposure to an extreme traumatic stressor 

involving direct personal experience of an 

event that involves actual or threatened death 

or serious injury, or other threat to one’s physical integrity; or witnessing an event that 

involves death, injury, or a threat to the physical integrity of another person; or learning 

about unexpected or violent death, serious 

harm, or threat of death or injury experienced 

by a family member or other close associate 

(APA 2000, p. 463). Counselors should be 

aware that 

•The lifetime prevalence of PTSD among 

adults in the United States is about 8 percent. 

•Among high-risk individuals (those who 

have survived rape, military combat, and 

captivity or ethnically or politically motivated internment and genocide), the proportion of those with PTSD ranges from 

one-third to one-half. 

•Among clients in substance abuse treatment, 

PTSD is two to three times more common in 

women than in men. 

•The rate of PTSD among people with substance use disorders is 12 to 34 percent; for 

women with substance use disorders, it is 30 

to 59 percent (Brown and Wolfe 1994). 

•Women with substance abuse problems 

report a lifetime history of physical and/or 

sexual abuse ranging from 55 to 99 percent 

(Najavits et al. 1997). 

•Most women with this co-occurring disorder 

experienced childhood physical and/or sexual abuse; men with both disorders typically experienced crime victimization or war 

trauma. 

•Clinicians are advised not to overlook the 

possibility of PTSD in men. 

•People with PTSD and substance abuse are 

more likely to experience further trauma 

than people with substance abuse alone. 

•Because repeated trauma is common in 

domestic violence, child abuse, and some 

substance-using lifestyles (e.g., the drug 

trade), helping the client protect against 

future trauma may be an important part of 

work in treatment. 

•People with PTSD tend to abuse the most 

serious substances (cocaine and opioids); 

however, abuse of prescription medications, 

marijuana, and alcohol also are common. 

•From the client’s perspective, PTSD symptoms are a common trigger for substance 

use. 

•While under the influence of substances, a 

person may be more vulnerable to trauma—for example, a woman drinking at a 

bar may go home with a stranger and be 

assaulted. 

•As a counselor, it is important to recognize, 

and help clients understand, that becoming 

abstinent from substances does not resolve 

PTSD; both disorders must be addressed in 

treatment. 

Case Study: Counseling a 

Substance Abuse Treatment 

Client Who Binge Drinks and 

Has PTSD 

Caitlin P. is a 17-year-old American-Indian 

female who was admitted to an inpatient substance abuse treatment program after she tried 

to kill herself during a drunken episode. She 

has been binge drinking since age 12 and also 

has tried a wide variety of pills without caring 

what she is taking. She has a history of depression and burning her arms with cigarettes. She 

238 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
Diagnostic Features of PTSD 

The essential feature of posttraumatic stress disorder is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves 

actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an 

event that involves death, injury, or a threat to the physical integrity of another person; or learning about 

unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or 

other close associate (Criterion A1). The person’s response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). 

The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma and 

numbing of general responsiveness (Criterion C), and persistent symptoms of increased arousal (Criterion 

D). The full symptom picture must be present for more than 1 month (Criterion E), and the disturbance 

must cause clinically significant distress or impairment in social, occupational, or other important areas of 

functioning (Criterion F). 

Diagnostic criteria for PTSD 

A. The person has been exposed to a traumatic event in which both of the following were present: 

(1) The person experienced, witnessed, or was confronted with an event or events that involved actual or 

threatened death or serious injury, or a threat to the physical integrity of self or others. 

(2) The person’s response involved intense fear, helplessness, or horror. Note: In children, this may be 

expressed instead by disorganized or agitated behavior. 

B. The traumatic event is persistently reexperienced in one (or more) of the following ways: 

(1) Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma 

are expressed. 

(2) Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. 

(3) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, 

illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur. 

(4) Intense psychological distress at exposure to internal or external cues that symbolize or resemble an 

aspect of the traumatic event. 

(5) Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect 

of the traumatic event. 

C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: 

(1) Efforts to avoid thoughts, feelings, or conversations associated with the trauma 

(2) Efforts to avoid activities, places, or people that arouse recollections of the trauma 

(3) Inability to recall an important aspect of the trauma 

(4) Markedly diminished interest or participation in significant activities 

(5) Feeling of detachment or estrangement from others 

(6) Restricted range of affect (e.g., unable to have loving feelings) 

(7) Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span) 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 239 
D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of 

the following: 

(1) Difficulty falling or staying asleep 

(2) Irritability or outbursts of anger 

(3) Difficulty concentrating 

(4) Hypervigilance 

(5) Exaggerated startle response 

E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month. 

F.	 	The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 

Specify if:



Acute: duration of symptoms is less than 3 months



Chronic: duration of symptoms is 3 months or more



Specify if:



With Delayed Onset: onset of symptoms is at least 6 months after the stressor



Source: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 463, 467, 468). 

was date-raped at age 15 and did not tell anyone except a close friend. She was afraid to tell 

her family for fear that they would think less of 

her for not preventing or fighting off the 

attack. 

In treatment, she worked with staff to try to 

gain control over her repeated self-destructive behavior. Together they worked on developing compassion for herself, created a safety 

plan to encourage her to reach out for help 

when in distress, and began a log to help her 

identify her PTSD symptoms so that she 

could recognize them more clearly. When she 

had the urge to drink, drug, or burn herself, 

she was guided to try to “bring down” the 

feelings through grounding, rethink the situation, and reassure herself that she could get 

through it. She began to see that her substance use had been a way to numb the pain. 

Discussion: Counselors can be very important in helping clients gain control over PTSD 

symptoms and self-destructive behavior associated with trauma. Providing specific coping 

strategies and a lot of encouragement typically are well received by PTSD/substance abuse 

treatment clients, who may want to learn how 

to be able to overcome the emotional roller 

coaster of the disorders. Notice that in such 

early-phase treatment, detailed exploration of 

the past is not generally advised. 

Eating Disorders 

What Counselors Should 

Know About Substance Abuse 

and Eating Disorders 

The essential features of anorexia nervosa are 

that the individual refuses to maintain a minimal normal body weight, is intensely afraid of 

gaining weight, and exhibits a significant disturbance in the perception of the shape or size 

of his or her body. The essential features of 

bulimia nervosa are binge eating and inappropriate compensatory methods to prevent weight 

gain. In dealing with persons who have either 

disorder, counselors should be aware of the following: 

• The prevalence of bulimia nervosa is elevated 

in women presenting for substance abuse 

treatment. 

240 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
• Studies of individuals in inpatient substance abuse treatment 

centers (as assessed via questionnaire) suggest that approximately 15 percent of women and 

1 percent of men had a DSMIII-R eating disorder (primarily 

bulimia nervosa) in their lifetime (Hudson et al. 1992). 

• Substance abuse is more common in bulimia nervosa than in 

anorexia nervosa. 

• Individuals with eating disorders are significantly more likely to use stimulants and significantly less likely to use opioids 

than other individuals undergoing substance abuse treatment 

who do not have a co-occurring 

eating disorder. 

• Many individuals alternate 

between substance abuse and 

eating disorders. 

• Alcohol and drugs such as marijuana can disinhibit appetite 

(i.e., remove normal restraints 

on eating) and increase the risk 

of binge eating as well as relapse 

in individuals with bulimia nervosa. 

• Individuals with eating disorders experience craving, tolerance, and withdrawal from drugs associated with purging, 

such as laxatives and diuretics. 

• Women with eating disorders often abuse 

pharmacological agents ingested for the purpose of weight loss, appetite suppression, and 

purging. Among these drugs are prescription 

and over-the-counter diet pills, laxatives, 

diuretics, and emetics. Nicotine and caffeine 

also must be considered when assessing substance abuse in women with eating disorders. 

• Several studies have suggested that the presence of co-occurring substance-related disorders does not affect treatment outcome 

adversely for bulimia nervosa. 

Advice to the Counselor: 

Counseling a Client With PTSD 

• Anticipate proceeding slowly with a client who is diagnosed with or has symptoms of PTSD. Consider the effect 

of a trauma history on the client’s current emotional 

state, such as an increased level of fear or irritability. 

• Develop a plan for increased safety where warranted. 

• Establish both perceived and real trust. 

• Respond more to the client’s behavior than her words. 

• Limit questioning about details of trauma. 

• Recognize that trauma injures an individual’s capacity for 

attachment. The establishment of a trusting treatment 

relationship will be a goal of treatment, not a starting 

point. 

• Recognize the importance of one’s own trauma history 

and countertransference. 

• Help the client learn to de-escalate intense emotions. 

• Help the client to link PTSD and substance abuse. 

• Provide psychoeducation about PTSD and substance 

abuse. 

• Teach coping skills to control PTSD symptoms. 

• Recognize that PTSD/substance abuse treatment clients 

may have a more difficult time in treatment and that 

treatment for PTSD may be long term, especially for 

those who have a history of serious trauma. 

• Help the client access long-term PTSD treatment and 

refer to trauma experts for trauma exploratory work. 

• Further studies are required to assess how 

the presence of an eating disorder affects 

substance abuse treatment and how best to 

integrate treatment for those with both conditions. This condition is quite serious and can 

be fatal. Treat it accordingly. 

• Individuals with eating disorders experience 

urges (or cravings) for binge foods similar to 

urges for drugs. 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 241 
Case Study: The History of a 

Substance Abuse Treatment 

Client With an Eating Disorder 

Mandy H. was 28 years old, Caucasian, 5’10” 

and 106 pounds when she first presented to 

the eating disorders service. She reported 4 

years of untreated bingeing and self-induced 

vomiting. In the months prior to presentation 

she had quit her job and was spending days 

locked in her mother’s house doing nothing 

but bingeing and vomiting, up to 20 times per 

day. She had large ulcers and infected 

scrapes in her mouth as a result of inserting 

objects down her throat to induce vomiting. 

She denied the use of alcohol, drugs, or other 

substances to induce purging. Her mother 

and boyfriend had substantial difficulties 

with alcohol abuse. She was admitted to the 

hospital and had great difficulties complying 

with unit rules. Vomitus was found hidden in 

her room and other clients’ rooms; she was 

caught smoking numerous times in the nonsmoking ward. She stole objects from staff 

and other clients to insert down her throat to 

induce vomiting. 

Although she was able to gain 10 pounds during her hospital stay, very little progress was 

made with the cognitive features of her bulimia nervosa. During subsequent outpatient followup, she managed to normalize her eating 

and reach a high weight of 125; however, she 

soon dropped out of treatment. One year 

later she presented again to the emergency 

room, this time weighing 103 pounds and 

intoxicated. Although she had managed to 

stop bingeing and purging, she had been 

restricting her food intake severely to about 

250 calories per day from food (not including 

the amount of calories she took in the form of 

alcohol). She had been drinking excessively 

and smoking marijuana with her boyfriend. 

Her therapist searched for a treatment program for uninsured individuals that specialized in substance abuse and that could 

address the added complexity of co-occurring 

disordered eating. 

Mandy H.’s therapist found a residential substance abuse treatment program that considered itself to have a balanced substance abuse 

and mental health approach, with a specialized dual disorders program for women who 

met American Society of Addiction Medicine 

Dual Diagnosis Enhanced criteria. The program offered group and individual counseling 

using the Dialectical Behavior Therapy (DBT) 

method. The therapist’s use of DBT included 

psychosocial groups for skills training, individual psychotherapy to strengthen individual skills and increase motivation, and telephone contact with the therapist when needed 

to foster generalization of skills to everyday 

life outside the treatment context (Linehan et 

al. 1999). The woman in charge of the DBT 

component of the treatment services was 

delighted to form a collaborative relationship 

with Mandy H.’s eating disorder therapist. 

Once during Mandy H.’s treatment (with 

Mandy H.’s permission, and the permission of 

the DBT group), Mandy H.’s eating disorders 

therapist sat in on the substance abuse treatment agency’s team treatment meeting and 

observed the DBT group counseling session 

that day. Mandy H.’s eating disorders therapist also was able to help Mandy H. get 

Medicaid coverage for her residential substance abuse treatment under the State’s program for clients with severe and persistent 

mental illness by demonstrating the persistence of Mandy H.’s COD based on her hospital stay the prior year and her current 

severe, complex, co-occurring conditions. 

Mandy H. did very well during her residential 

stay, and she responded positively to AA. 

From the extensive intake information and 

collateral reports from relatives, Mandy H.’s 

substance abuse treatment counselor learned 

that Mandy H.’s family tree was filled with 

people who had developed alcoholism, including a grandmother who might well have developed an addiction to sleeping pills and/or 

tranquilizers in the 1960s. Since the substance abuse treatment counselor also had a 

family tree with many people with chemical 

dependencies, the counselor could understand how Mandy H. could identify closely 

242 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
Anorexia Nervosa 

Diagnostic features 

The essential features of anorexia nervosa are that the individual refuses to maintain a minimally normal body 

weight, is intensely afraid of gaining weight, and exhibits a significant disturbance in the perception of the shape 

or size of his or her body (see below Criterion A). In addition, postmenarcheal females with this disorder are 

amenorrheic. (The term anorexia is a misnomer because loss of appetite is rare.) Individuals with this disorder 

intensely fear gaining weight or becoming fat (Criterion B). This intense fear of becoming fat is usually not alleviated by the weight loss. In fact, concern about weight gain often increases even as actual weight continues to 

decrease. The experience and significance of body weight and shape are distorted in these individuals (Criterion 

C). In postmenarcheal females, amenorrhea (due to abnormally low levels of estrogen secretion that are due in 

turn to diminished pituitary secretion of follicle-stimulating hormone and luteinizing hormone) is an indicator of 

physiological dysfunction in Anorexia Nervosa (Criterion D). 

Diagnostic criteria for anorexia nervosa 

A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss 

leading to maintenance of body weight less than 85 percent of that expected; or failure to make expected 

weight gain during period of growth, leading to body weight less than 85 percent of that expected). 

B. Intense fear of gaining weight or becoming fat, even though underweight. 

C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight 

or shape on self-evaluation, or denial of the seriousness of the current low body weight. 

D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A 

woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogen, administration.) 

Specify type:



Restricting Type: During the current episode of Anorexia Nervosa, the person has not regularly



engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, 

diuretics, or enemas). 

Binge-Eating/Purging Type: During the current episode of Anorexia Nervosa, the person has regularly 

engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, 

diuretics, or enemas). 

Bulimia Nervosa 

Diagnostic features 

The essential features of bulimia nervosa are binge eating and inappropriate compensatory methods to prevent 

weight gain. In addition, the self-evaluation of individuals with bulimia nervosa is excessively influenced by 

body shape and weight. To qualify for the diagnosis, the binge eating and the inappropriate compensatory 

behaviors must occur, on average, at least twice a week for 3 months (Criterion C). An episode of binge eating is 

also accompanied by a sense of lack of control (Criterion A2). Another essential feature of bulimia nervosa is 

the recurrent use of inappropriate compensatory behaviors to prevent weight gain (Criterion B). 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 243 
Individuals with bulimia nervosa place an excessive emphasis on body shape and weight in their self-evaluation, 

and these factors are typically the most important ones in determining self-esteem (Criterion D). However, a 

diagnosis of bulimia nervosa should not be given when the disturbance occurs only during episodes of anorexia 

nervosa (Criterion E). 

Diagnostic criteria for bulimia nervosa 

A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 

(1)		 Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely 

larger than most people would eat during a similar period of time and under similar circumstances 

(2)		 A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or 

control what or how much one is eating) 

B. Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. 

C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week 

for 3 months. 

D. Self-evaluation is unduly influenced by body shape and weight. 

E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. 

Specify type: 

Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-


induced vomiting or the misuse of laxatives, diuretics, or enemas. 


Nonpurging Type: during the current episode of Bulimia Nervosa, the person has used other inappro­


priate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in 

self-induced vomiting or the misuse of laxatives, diuretics, or enemas. 

Source: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 583, 584, 589-591, 594) 

with what people had to say at AA meetings, 

even without a lengthy history of heavy alcohol use. Mandy H. found that the strong 

attachment to alcohol expressed by others 

was what she was already experiencing, 

including her finding that until she knew 

where her drinking would be able to occur 

during the day, not much else could keep her 

attention. Mandy H. felt she had a similar 

addictive response to marijuana. 

The substance abuse treatment program 

directed Mandy H. to AA meetings that other 

people with co-occurring disorders attended. 

Mandy H. was able to find a sponsor who 

herself had a co-occurring depressive disorder, one that had been handled successfully 

with maintenance antidepressant medication. 

Mandy H. did well throughout treatment, and 

by the time she was in her sixth month of outpatient continuing care, she had gained 12 

pounds. At that point Mandy H. began to 

struggle with urges to binge and thoughts of 

inducing vomiting. Her eating disorders therapist contacted her continuing care substance 

abuse treatment counselor (the same woman 

who handled the DBT parts of the residential 

program). After discussing Mandy H.’s situation and improvement, the substance abuse 

treatment counselor agreed with the eating 

disorders counselor’s recommendation that 

Mandy H. see the substance abuse treatment 

program’s psychiatric consultant for possible 

use of an antidepressant to help with the 

emerging bingeing and purging concerns. The 

psychiatrist consultant saw Mandy H. and 

then called another psychiatrist who Mandy 

244 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
H.’s eating disorder therapist 

used regularly. After a brief discussion with the other psychiatrist, the psychiatrist treating 

Mandy H. prescribed 20 mg of 

fluoxetine and discussed with 

Mandy H. what to expect. 

It was helpful to Mandy H. to see 

the medication as part of how 

she could be empowered to take 

care of herself and to take care 

of her recovery. Mandy H. fully 

embraced the idea of being powerless over her use of alcohol, 

marijuana, or euphoria-producing drugs, as she saw that as a 

great help to her both in terms of 

averting thoughts about her 

weight and in terms of thoughts 

about whether just to smoke 

marijuana or have just a little 

wine, Mandy H.’s sponsor was 

able to share with Mandy H. her 

“research” with “just a little 

wine.” 

Advice to the Counselor: 

Counseling a Client With an 

Eating Disorder 

• Where possible, work closely with a professional who specializes in eating disorders. 

• Document through a comprehensive assessment the individual’s full repertoire of weight loss behaviors since people with eating disorders will often go to dangerous 

extremes to lose weight. 

• Conduct a behavioral analysis of the foods and substances 

of choice; high-risk times and situations for engaging in 

disordered eating and substance abuse behaviors; and 

the nature, pattern, and interrelationship of disordered 

eating and substance use. 

• Develop a treatment plan for both the eating and substance use disorder. 

• Employ psychoeducation and cognitive–behavioral techniques for bulimia nervosa. 

• Use adjunctive strategies such as nutritional consultation, 

the setting of a weight range goal, and observations at 

and between meal times for disordered eating behaviors. 

• Incorporate relapse prevention strategies to plan for a 

long course of treatment and several treatment episodes. 

Mandy H.’s COD were a diagnostic challenge for the treatment team. Her DBT counselor 

thought she had an additional borderline personality disorder, but the treatment team 

thought she should be re-evaluated after 3 to 

6 months of both sobriety and healthy eating, 

especially as Mandy H. had had regular but 

slow progress the prior year until she 

dropped out of treatment and began to drink 

and smoke marijuana. 

Indeed, with a year of sobriety and strong 

feelings of a new lease on life through 12-Step 

living, Mandy H. was eligible for State vocational rehabilitation assistance and entered 

college. Mandy H. still went to AA once a 

month, or more if she or her sponsor thought 

it wise, and she stayed in touch about once a 

week with her sponsor. Mandy H. attended 

monthly continuing care groups, and she saw 

her eating disorders therapist every other 

month. Mandy H. also continued to see the 

psychiatrist for medication management, and 

she had unproblematic increases in her medication to a full therapeutic dose appropriate 

for her. On rare occasions Mandy H. had 

thoughts about foregoing her medication, but 

with her counselor’s help she realized that 

such thoughts were akin to “stinking thinking” and often connected to some other reactions or concerns going on in other areas of 

her life. 

Discussion: How would Mandy H. have 

fared without comprehensive and integrated 

treatment? Mandy H.’s case history highlights 

the importance of assisting clients in therapeutic and extra-therapeutic ways, such as 

assisting with Medicaid and vocational rehabilitation eligibilities. Also, the importance of 

Mandy H.’s particular background and the 

reactions it engendered to AA is taken into 

consideration, while nonacute concerns about 

diagnostic concerns were put in abeyance. 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 245 
Last, the united front between the substance 

abuse counselor and persons involved in 

treatment of her mental disorder regarding 

medications and other aspects of treatment 

was helpful to Mandy H. maintaining her 

dual recovery. 

Pathological Gambling 

What Counselors Should 

Know About Substance Abuse 

and Pathological Gambling 

The essential feature of pathological gambling 

is persistent and recurrent maladaptive gambling behavior that disrupts personal, family, 

or vocational pursuits. Counselors should be 

aware that 

•Prevalence data for gambling regularly 

makes distinctions among “pathological” 

gamblers (the most severe category) and 

levels of “problem” gambling (less severe to 

moderate levels of difficulty). Recent general estimates (Gerstein et al. 1999; Shaffer et 

al. 1997) indicate about 1 percent of the 

U.S. general population could be classified 

as having pathological gambling, according 

to the diagnostic criteria below. Cogent considerations regarding prevalence are given 

in the DSM-IV-TR regarding variations due 

to the availability of gambling and seemingly greater rates in certain locations (e.g., 

Puerto Rico, Australia), which have been 

reported to be as high as 7 percent. Higher 

prevalence rates also have been reported in 

adolescents and college students, ranging 

from 2.8 to 8 percent (APA 2000). The general past-year estimate for pathological and 

problem gambling combined is roughly 3 

percent. This can be compared to past year 

estimates of alcohol abuse/dependence of 

9.7 percent and drug abuse/dependence of 

3.6 percent. 

•The rate of co-occurrence of pathological 

gambling among people with substance use 

disorders has been reported as ranging 

from 9 to 30 percent and the rate of substance abuse among individuals with pathological gambling has been estimated at 25 to 

63 percent. 

•Among pathological gamblers, alcohol has 

been found to be the most common substance of abuse. At minimum, the rate of 

problem gambling among people with substance use disorders is four to five times 

that found in the general population. 

•It is important to recognize that even 

though pathological gambling often is 

viewed as an addictive disorder, clinicians 

cannot assume that their knowledge or 

experience in substance abuse treatment 

qualifies them automatically to treat people 

with a pathological gambling problem. 

•With clients with substance use disorders 

who are pathological gamblers, it often is 

essential to identify specific triggers for 

each addiction. It is also helpful to identify 

ways in which use of addictive substances 

or addictive activities such as gambling act 

as mutual triggers. 

In individuals with COD, it is particularly 

important to evaluate patterns of substance use 

and gambling. The following bullets provide 

several examples: 

•Cocaine use and gambling may coexist as 

part of a broader antisocial lifestyle. 

•Someone who is addicted to cocaine may see 

gambling as a way of getting money to support drug use. 

•A pathological gambler may use cocaine to 

maintain energy levels and focus during 

gambling and sell drugs to obtain gambling 

money. 

•Cocaine may artificially inflate a gambler’s 

sense of certainty of winning and gambling 

skill, contributing to taking greater gambling risks. 

•The gambler may use drugs or alcohol as a 

way of celebrating a win or relieving 

depression. 

•One of the more common patterns that has 

been seen clinically is that of a sequential 

addiction. A frequent pattern is that someone who has had a history of alcohol depen246 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
Diagnostic Features of Pathological Gambling 

Source: Reprinted with permission from DSM-IV-TR (APA 2000, pp. 671, 674). 

The essential feature of pathological gambling is persistent and recurrent maladaptive gambling behavior 

(Criterion A) that disrupts personal, family, or vocational pursuits. The diagnosis is not made if the gambling 

behavior is better accounted for by a manic episode (Criterion B). 

Diagnostic criteria 

A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: 

(1) Is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble) 

(2) Needs to gamble with increasing amounts of money in order to achieve the desired excitement 

(3) Has repeated unsuccessful efforts to control, cut back, or stop gambling 

(4) Is restless or irritable when attempting to cut down or stop gambling 

(5) Gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) 

(6) After losing money gambling, often returns another day to get even (“chasing” one’s losses) 

(7) Lies to family members, therapist, or others to conceal the extent of involvement with gambling 

(8) Has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling 

(9) Has jeopardized or lost a significant relationship, job, or educational or career opportunity because 

of gambling 

(10) Relies on others to provide money to relieve a desperate financial situation caused by gambling 

B. The gambling behavior is not better accounted for by a Manic Episode. 

dence—often with many years of recovery 

and AA attendance—develops a gambling 

problem. 

Case Study: Counseling a 

Substance Abuse Treatment 

Client With a Pathological 

Gambling Disorder 

Louis Q. is a 56-year-old, divorced Caucasian 

male who presented through the emergency 

room, where he had gone complaining of 

chest pain. After cardiovascular problems 

were ruled out, he was asked about stressors 

that may have contributed to chest pain. 

Louis Q. reported frequent gambling and significant debt. However, he has never sought 

any help for gambling problems. 

The medical staff found that Louis Q. had a 

30-year history of alcohol abuse, with a significant period of meeting criteria for alcohol 

dependence. He began gambling at age 13. 

Currently, he meets criteria for both alcohol 

dependence and pathological gambling. He 

has attended AA a few times in the past for 

very limited periods. 

He was referred to a local substance abuse 

treatment agency. Assessment indicated that 

drinking was a trigger for gambling, as well as 

a futile attempt at self-medication to manage 

depression related to gambling losses. The 

precipitating event for seeking help was anxiety related to embezzling money from his job 

and fear that his embezzlement was going to 

be found by an upcoming audit. 

A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 247 
Advice to the Counselor: 

Counseling a Client With Pathological 

Gambling Disorder 

• Carefully assess use and frequency of sports events, 

scratch tickets, games of chance, and bets. 

• Ask if the client is at any physical risk regarding owing 

money to people who collect on such debts. 

• Treat the disorders as separate but interacting problems. 

• Become fluent in the languages of substance abuse and 

of gambling. 

• Understand the similarities and differences of substance 

use disorders and pathological gambling. 

• Utilize all available 12-Step and other mutual support 

groups. 

• Recognize that a client’s motivation level may be at different points for dealing with each disorder. 

• Use treatments that combine 12-Step, psychoeducation, 

group therapy and cognitive–behavioral approaches. 

• Use separate support groups for gambling and for alcohol and/or drug dependence. While the groups can supplement each other, they cannot substitute for each 

other. 

During the evaluation, it became clear that 

treatment would have to address both his 

gambling as well as his alcohol dependence, 

since these were so intertwined. Education 

was provided on both disorders, using standard information at the substance abuse 

treatment agency as well as materials from 

Gamblers Anonymous (GA). Group and individual therapy repeatedly pointed out the 

interaction between the disorders and the 

triggers for each, emphasizing the development of coping skills and relapse prevention 

strategies for both disorders. Louis Q. also 

was referred to a local GA meeting and was 

fortunate to have another member of his 

addictions group to guide him there. The family was involved in treatment planning and 

money management, including efforts to organize, structure, and monitor debt repayment. 

Legal assistance was obtained to advise him 

on potential legal charges due to embezzlement at work. He began attending both AA 

and GA meetings, obtaining sponsors in both 

programs. 

Discussion: The counselor 

takes time to establish the relationship of the two disorders. He 

takes the gambling problem seriously as a disorder in itself, 

rather than assuming it would go 

away when the addiction was 

treated. Even though his agency 

did not specialize in gambling 

addiction treatment, he was able 

to use available community 

resources (e.g., GA) as a source 

of educational material and a 

referral. He recognized the 

importance of regular group 

involvement for Louis Q. and 

also knew it was critical to support the family in working 

through existing problems and 

trying to avoid new ones. 

Conclusion 

The information contained in 

this chapter can serve as a quick 

reference for the substance 

abuse counselor when working 

with clients who have the mental disorders 

described or who may be suicidal. As noted 

above, appendix D provides more extensive 

information. The limited aims of the panel in 

providing this material are to increase substance abuse treatment counselors’ familiarity 

with mental disorders terminology and criteria, as well as to provide advice on how to 

proceed with clients who demonstrate these 

disorders. The panel encourages counselors 

to continue to increase their understanding of 

mental disorders by using the resource material referenced in each section, attending 

courses and conferences in these areas, and 

engaging in dialog with mental health professionals who are involved in treatment. At the 

same time, the panel urges continued work to 

develop improved treatment approaches that 

address substance use in combination with 

specific mental disorders, as well as better 

translation of that work to make it more 

accessible to the substance abuse field. 

248 A Brief Overview of Specific Mental Disorders and Cross-Cutting Issues 
9 Substance-Induced 

Disorders 

In This 

Chapter... 

Description 

Alcohol



Caffeine



Cocaine and



Amphetamines



Hallucinogens



Nicotine



Opioids



Sedatives



Diagnostic



Considerations



Case Studies:



Identifying



Disorders



Overview 

The toxic effects of substances can mimic mental illness in ways that can 

be difficult to distinguish from mental illness. This chapter focuses on 

symptoms of mental illness that are the result of substance abuse—a 

condition referred to as “substance-induced mental disorders.” 

Description 

As defined in the Diagnostic and Statistical Manual of Mental 

Disorders, 4th edition, Text Revision (American Psychiatric 

Association [APA] 2000) (DSM-IV-TR), substance-induced disorders 

include: 

• Substance-induced delirium 

• Substance-induced persisting dementia 

• Substance-induced persisting amnestic disorder 

• Substance-induced psychotic disorder 

• Substance-induced mood disorder 

• Substance-induced anxiety disorder 

• Hallucinogen persisting perceptual disorder 

• Substance-induced sexual dysfunction 

• Substance-induced sleep disorder 

Substance-induced disorders are distinct from independent co-occurring mental disorders in that all or most of the psychiatric symptoms 

are the direct result of substance use. This is not to state that substance-induced disorders preclude co-occurring mental disorders, 

only that the specific symptom cluster at a specific point in time is 

more likely the result of substance use, abuse, intoxication, or withdrawal than of underlying mental illness. A client might even have 

both independent and substance-induced mental disorders. For example, a client may present with well-established independent and con249 
trolled bipolar disorder and alcohol dependence in remission, but the same client could 

be experiencing amphetamine-induced auditory hallucinations and paranoia from an 

amphetamine abuse relapse over the last 3 

weeks. 

Symptoms of substance-induced disorders 

run the gamut from mild anxiety and depression (these are the most common across all 

substances) to full-blown manic and other 

psychotic reactions (much less common). The 

“teeter-totter principle”—i.e., what goes up 

must come down—is useful to predict what 

kind of syndrome or symptoms might be 

caused by what substances. For example, 

acute withdrawal symptoms from physiological depressants such as alcohol and benzodiazepines are hyperactivity, elevated blood 

pressure, agitation, and anxiety (i.e., the 

shakes). On the other hand, those who 

“crash” from stimulants are tired, withdrawn, and depressed. Virtually any substance taken in very large quantities over a 

long enough period can lead to a psychotic 

state. 

Because clients vary greatly in how they 

respond to both intoxication and withdrawal 

given the same exposure to the same substance, and also because different substances 

may be taken at the same time, prediction of 

any particular substance-related syndrome 

has its limits. What is most important is to 

continue to evaluate psychiatric symptoms 

and their relationship to abstinence or ongoing substance abuse over time. Most substance-induced symptoms begin to improve 

within hours or days after substance use has 

stopped. Notable exceptions to this are psychotic symptoms caused by heavy and longterm amphetamine abuse and the dementia 

(problems with memory, concentration, and 

problemsolving) caused by using substances 

directly toxic to the brain, which most commonly include alcohol, inhalants like gasoline, 

and again amphetamines. Following is an 

overview of the most common classes of substances of abuse and the accompanying psychiatric symptoms seen in intoxication, withdrawal, or chronic use. 

Alcohol 

In most people, moderate to heavy consumption is associated with euphoria, mood lability, decreased impulse control, and increased 

social confidence (i.e., getting high). Such 

symptoms might even appear “hypomanic.” 

However these often are followed with nextday mild fatigue, nausea, and dysphoria (i.e., 

a hangover). In a person who has many life 

stresses, losses, and struggles, which is often 

the case as addiction to alcohol proceeds, the 

mood lability and lowered impulse control 

can lead to increased rates of violence toward 

others and self. Prolonged drinking increases 

the incidence of dysphoria, anxiety, and such 

violence potential. Symptoms of alcohol withdrawal include agitation, anxiety, tremor, 

malaise, hyperreflexia (exaggeration of reflexes), mild tachycardia (rapid heart beat), 

increasing blood pressure, sweating, insomnia, nausea or vomiting, and perceptual distortions. 

Following acute withdrawal (a few days), 

some people will experience continued mood 

instability, fatigue, insomnia, reduced sexual 

interest, and hostility for weeks, so called 

“protracted withdrawal.” Differentiating protracted withdrawal from a major depression 

or anxiety disorder is often difficult. More 

severe withdrawal is characterized by severe 

instability in vital signs, agitation, hallucinations, delusions, and often seizures. The best 

predictor of whether this type of withdrawal 

may happen again is if it happened before. 

Alcohol-induced deliriums after high-dose 

drinking are characterized by fluctuating 

mental status, confusion, and disorientation 

and are reversible once both alcohol and its 

withdrawal symptoms are gone, while by definition, alcohol dementias are associated with 

brain damage and are not entirely reversible 

even with sobriety. 

250 Substance-Induced Disorders 
Caffeine 

When consumed in large quantities, caffeine 

can cause mild to moderate anxiety, though 

the amount of caffeine that leads to anxiety 

varies. Caffeine is also associated with an 

increase in the number of panic attacks in 

individuals who are predisposed to them. 

Cocaine and Amphetamines 

Mild to moderate intoxication from cocaine, 

methamphetamine, or other stimulants is 

associated with euphoria, and a sense of 

internal well-being, and perceived increased 

powers of thought, strength, and accomplishment. In fact, low to moderate doses of 

amphetamines may actually increase certain 

test-taking skills temporarily in those with 

attention deficit disorders (see this in 

appendix D) and even in people who do not 

have attention deficit disorders. However, as 

more substance is used and intoxication 

increases, attention, ability to concentrate, 

and function decrease. 

With street cocaine and methamphetamines, 

dosing is almost always beyond the functional 

window. As dosage increases, the chances of 

impulsive dangerous behaviors, which may 

involve violence, promiscuous sexual activity, 

and others, also increases. Many who become 

chronic heavy users go on to experience temporary paranoid delusional states. As mentioned above, with methamphetamines, these 

psychotic states may last for weeks, months, 

and even years. Unlike schizophrenic psychotic states, the client experiencing a paranoid state induced by cocaine more likely has 

intact abstract reasoning and linear thinking 

and the delusions are more likely paranoid 

and less bizarre (Mendoza and Miller 1992). 

After intoxication comes a crash in which the 

person is desperately fatigued, depressed, 

and often craves more stimulant to relieve 

these withdrawal symptoms. This dynamic is 

why it is thought that people who abuse stimulants often go on week- or month-long binges 

and have a hard time stopping. At some point 

the ability of stimulants to push the person 

back into a high is lost (probably through 

washing out of neurotransmitters), and then a 

serious crash ensues. 

Even with several weeks of abstinence, many 

people who are addicted to stimulants report 

a dysphoric state that is marked by anhedonia (absence of pleasure) and/or anxiety, but 

which may not meet the symptom severity criteria to qualify as DSM-IV Major Depression 

(Rounsaville et al. 1991). These anhedonic 

states can persist for weeks. As mentioned 

above, heavy, long-term amphetamine use 

appears to cause long-term changes in the 

functional structure of the brain, and this is 

accompanied by long-term problems with concentration, memory, and, at times, psychotic 

symptoms. Month-long methamphetamine 

binges followed by week- or month-long alcohol binges, a not uncommon pattern, might 

appear to be “bipolar” disorder if the drug 

use is not discovered. For more information, 

see the National Institute on Drug Abuse Web 

site (http://www.nida.nih.gov). 

Hallucinogens 

Hallucinogens produce visual distortions and 

frank hallucinations. Some people who use 

hallucinogens experience a marked distortion 

of their sense of time and feelings of depersonalization. Hallucinogens may also be associated with drug-induced panic, paranoia, 

and even delusional states in addition to the 

hallucinations. Hallucinogen hallucinations 

usually are more visual (e.g., enhanced colors 

and shapes) as compared to schizophrenictype hallucinations, which tend to be more 

auditory (e.g., voices). The existence of a 

marijuana-induced psychotic state has been 

debated (Gruber and Pope 1994), although a 

review of the research suggests that there is 

no such entity. A few people who use hallucinogens experience chronic reactions, involving prolonged psychotic reactions, depression, exacerbations of preexisting mental disorders, and flashbacks. The latter are symptoms that occur after one or more psychedelic 

“trips” and consist of flashes of light and 

after-image prolongation in the periphery. 

Substance-Induced Disorders 251 
The DSM-IV defines flashbacks as a “hallucinogen persisting perception disorder.” A 

diagnosis requires that they be distressing or 

impairing to the client (APA 1994, p. 234). 

Nicotine 

Clients who are dependent on nicotine are 

more likely to experience depression than 

people who are not addicted to it; however, it 

is unclear how much this is cause or effect. In 

some cases, the client may use nicotine to regulate mood. Whether there is a causal relationship between nicotine use and the symptoms of depression remains to be seen. At 

present, it can be said that many persons who 

quit smoking do experience both craving and 

depressive symptoms to varying degrees, 

which are relieved by resumption of nicotine 

use (see chapter 8 for more information on 

nicotine dependence). 

Opioids 

Opioid intoxication is characterized by 

intense euphoria and well-being. Withdrawal 

results in agitation, severe body aches, gastrointestinal symptoms, dysphoria, and craving to use more opioids. Symptoms during 

withdrawal vary—some will become acutely 

anxious and agitated, while others will experience depression and anhedonia. Even with 

abstinence, anxiety, depression, and sleep 

disturbance can persist for weeks as a protracted withdrawal syndrome. Again, differentiating this from major depression or anxiety is difficult and many clinicians may just 

treat the ongoing symptom cluster. For many 

people who become opioid dependent, and 

then try abstinence, these ongoing withdrawal 

symptoms are so powerful that relapse occurs 

even with the best of treatments and client 

motivation. For these clients, opioid replacement therapy (methadone, suboxone, etc.) 

becomes necessary and many times life saving. There are reports of an atypical opioid 

withdrawal syndrome characterized by delirium after abrupt cessation of methadone 

(Levinson et al. 1995). Such clients do not 

appear to have the autonomic symptoms typically seen in opioid withdrawal. Long-term 

use of opioids is commonly associated with 

moderate to severe depression. 

Phencyclidine (PCP) causes dissociative and 

delusional symptoms, and may lead to violent 

behavior and amnesia of the intoxication. 

Zukin and Zukin (1992) report that people 

who use PCP and who exhibit an acute psychotic state with PCP are more likely to experience another with repeated use. 

Sedatives 

Acute intoxication with sedatives like 

diazepam is similar to what is experienced 

with alcohol. Withdrawal symptoms are also 

similar to alcohol and include mood instability with anxiety and/or depression, sleep disturbance, autonomic hyperactivity, tremor, 

nausea or vomiting, and, in more severe 

cases, transient hallucinations or illusions 

and grand mal seizures. There are reports of 

a protracted withdrawal syndrome characterized by anxiety, depression, paresthesias, 

perceptual distortions, muscle pain and 

twitching, tinnitus, dizziness, headache, derealization and depersonalization, and 

impaired concentration. Most symptoms 

resolve within weeks, though some symptoms, 

such as anxiety, depression, tinnitus (ringing 

in the ears), and paresthesias (sensations such 

as prickling, burning, etc.), have been reported to last a year or more after withdrawal in 

rare cases. No chronic dementia-type syndromes have been characterized with chronic 

use; however, many people who use sedatives 

chronically seem to experience difficulty with 

anxiety symptoms, which respond poorly to 

other anxiety treatments. 

Diagnostic 

Considerations 

Diagnoses of substance-induced mental disorders will typically be provisional and will 

require reevaluation—sometimes repeatedly. 

Many apparent acute mental disorders may 

252 Substance-Induced Disorders 
really be substance-induced disorders, such 

as in those clients who use substances and 

who are acutely suicidal (see chapter 8 and 

appendix D for more on suicidality and drug 

use). 

Criteria for Diagnosis of Substance-Induced Mood Disorders 

Source: APA 1994. 

1. A prominent and persistent disturbance in mood predominates, characterized by (a) a depressed mood or 

markedly diminished interest or pleasure in activities, or (b) an elevated, expansive, or irritable mood. 

2. There is evidence from the history, physical examination, or laboratory findings that the symptoms developed during or within a month after substance intoxication or withdrawal, or medication use, is etiologically 

related to the mood disturbance. 

3. The disturbance is not better explained by a mood disorder. 

4. The disturbance did not occur exclusively during a delirium. 

5. The symptoms cause clinically significant distress or impairment. 

Some people who have what appear to be substance-induced disorders may turn out to 

have both a substance-induced disorder and 

an independent mental disorder. For most 

people who are addicted to substances, drugs 

eventually become more important than jobs, 

friends, family, and even children. These 

changes in priorities often look, sound, and 

feel like a personality disorder, but diagnostic 

clarity regarding personality disorders in general is difficult, and in clients with substancerelated disorders the true diagnostic picture 

might not emerge or reveal itself for weeks or 

months. Moreover, it is not unusual for the 

symptoms of a personality disorder to clear 

with abstinence—sometimes even fairly early 

in recovery. Preexisting mood state, personal 

expectations, drug dosage, and environmental 

surroundings all warrant consideration in 

developing an understanding of how a particular client might experience a substanceinduced disorder. Treatment of the substance 

use disorder and an abstinent period of weeks 

or months may be required for a definitive 

diagnosis of an independent, co-occurring 

mental disorder. As described in chapter 4 on 

assessment, substance abuse treatment programs and clinical staff can concentrate on 

screening for mental disorders and determining the severity and acuity of symptoms, 

along with an understanding of the client’s 

support network and overall life situation. 

The text box above provides an example of 

the diagnostic criteria for one substanceinduced disorder—substance-induced mood 

disorders. 

Case Studies: 

Identifying Disorders 

George M. is a 37-year-old divorced male who 

was brought into the emergency room intoxicated. His blood alcohol level was .152, and 

the toxicology screen was positive for cocaine. 

He was also suicidal (“I’m going to do it right 

this time!”). He has a history of three psychiatric hospitalizations and two inpatient substance abuse treatments. Each psychiatric 

admission was preceded by substance use. 

George M. has never followed through with 

mental health care. He has intermittently 

attended Alcoholics Anonymous, but not 

recently. 

Teresa G. is a 37-year-old divorced female 

who was brought into a detoxification unit 4 

days ago with a blood alcohol level of .150. 

She is observed to be depressed, withdrawn, 

with little energy, fleeting suicidal thoughts, 

and poor concentration, but states she is just 

fine, not depressed, and life was good last 

week before her relapse. She has never used 

drugs (other than alcohol), and began drinkSubstance-Induced Disorders 253 
ing alcohol only 3 years ago. However, she 

has had several alcohol-related problems 

since then. She has a history of three psychiatric hospitalizations for depression, at ages 

19, 23, and 32. She reports a positive 

response to antidepressants. She is currently 

not receiving mental health services or substance abuse treatment. She is diagnosed with 

alcohol dependence (relapse) and substanceinduced mood disorder, with a likely history 

of, but not active, major depression. 

Discussion 

Many factors must be examined when making 

initial diagnostic and treatment decisions. For 

example, if George M.’s psychiatric admissions were 2 or 3 days long, usually with discharges related to leaving against medical 

advice, decisions about diagnosis and treatment would be different (i.e., it is likely this 

is a substance-induced suicidal state and 

referral at discharge should be to a substance 

abuse treatment agency rather than a mental 

health center) than if two of his psychiatric 

admissions were 2 or 3 weeks long with clearly defined manic and psychotic symptoms 

continuing throughout the course, despite 

aggressive use of mental health care and medication (this is more likely a person with both 

bipolar disorder and alcohol dependence who 

requires integrated treatment for both his 

severe alcoholism and bipolar disorder). 

Similarly, if Teresa G. had become increasingly depressed and withdrawn over the past 

3 months, and had for a month experienced 

disordered sleep, poor concentration, and 

suicidal thoughts, she would be best diagnosed with major depression with an acute 

alcohol relapse rather than substanceinduced mood disorder secondary to her alcohol relapse. 

254 Substance-Induced Disorders 
                 

   

               

                 

             

             

                 

               

     

                   

               

             

     

                   

               

           

           

                     

         

               

             

                   

             

         

                 

             

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Appendix B:

Acronyms

AA Alcoholics Anonymous

AAAP American Academy of Addiction Psychiatry

AACP American Association of Community Psychiatrists

ACA Adult Children of Alcoholics

ACT Assertive Community Treatment

AD/HD attention deficit/hyperactivity disorder

ADM Alcohol, Drug Abuse or Mental Disorders

AHRQ Agency for Healthcare Research and Quality (formerly

AHCPR)

AIDS acquired immunodeficiency syndrome

AOD alcohol and other drugs

AOS addiction only services

APA American Psychological Association; American Psychiatric

Association

APD antisocial personality disorder

APPI American Psychiatric Publishing, Inc.

ASAM American Society of Addiction Medicine

ASI Addiction Severity Index

ATTC Addiction Technology Transfer Center

AUDIT Alcohol Use Disorders Identification Test

AUS Alcohol Use Scale

309
BAI Beck Anxiety Inventory

BDI Beck Depression Inventory

BED binge­eating disorder

BPD borderline personality disorder

BSI­18 Brief Symptom Inventory­18

CA Cocaine Anonymous

CAMI chemically abusing mentally ill,

or chemically addicted and mentally ill

CBT cognitive–behavioral therapy

CCISC Comprehensive Continuous

Integrated System of Care

CINA Clinical Institute Narcotic

Assessment

CIWA­Ar Clinical Institute Withdrawal

Assessment

CM Contingency Management

CMHS Center for Mental Health

Services (SAMHSA)

COD co­occurring disorders (in this

TIP, specifically co­occurring

substance abuse and one or more

mental health disorders)

CONTAC Consumer Organization and

Networking Technical Assistance

Center

CQI Continuous Quality Improvement

CSAP Center for Substance Abuse

Prevention (SAMHSA);

Corrections Substance Abuse

Program

CSAT Center for Substance Abuse

Treatment (SAMHSA)

CTU Crisis Triage Unit

DALI Dartmouth Assessment of

Lifestyle Inventory

DAST Drug Abuse Screening Test

DATOS Drug Abuse Treatment Outcome

Studies

DBT Dialectical Behavior Therapy

DDC dual diagnosis capable

DDE dual diagnosis enhanced

DDRN Dual Diagnosis Recovery

Network

DID dissociative identity disorder,

formerly known as multiple personality disorder

DIS Diagnostic Interview Schedule

DSM­IV Diagnostic and Statistical Manual

of Mental Disorders, 4th Edition

DTR Double Trouble in Recovery

DUI driving under the influence

DUS Drug Use Scale

EAP employee assistance program

ECA Epidemiological Catchment Area

ER emergency room

FY fiscal year

GA Gamblers Anonymous

GAD general anxiety disorder

GAIN Global Appraisal of Individual

Needs

HIP HIV Integration Project

HIPAA Health Insurance Portability and

Accountability Act

HIV human immunodeficiency virus

ICM Intensive Case Management

ICOPSD individuals with co­occurring

psychiatric and substance disorders

310 Acronyms
IOM Institute of Medicine

LOCUS Level of Care Utilization System

MAST Michigan Alcoholism Screen Test

MATCH Matching Alcoholism Treatment

to Client Heterogeneity

MDDA Manic Depressive and Depressive

Association

MET Motivational Enhancement

Techniques

MFIR Men’s Forensic Intensive

Recovery

MHSF­III Mental Health Screening FormIII

MI Motivational Interviewing

MICA mentally ill chemically addicted

or affected, mentally ill chemical

abusing, or mentally ill chemical

abuser

MICD mentally ill chemically dependent

MIDAS Mental Illness Drug and Alcohol

Screening

MINI Mini­International

Neuropsychiatric Interview

MISA mentally ill substance abuser

MISU mentally ill substance using

MMPI Minnesota Multiphasic

Personality Inventory

MTC Modified Therapeutic

Community

NA Narcotics Anonymous

NAADAC National Association of

Alcoholism and Drug Abuse

Counselors

NAC National Advisory Council

NAMI National Alliance for the Mentally

Ill

NASADAD National Association of State

Alcohol and Drug Abuse

Directors

NASMHPD National Association of State

Mental Health Program Directors

NCADI National Clearinghouse for

Alcohol and Drug Information

NCI Na’nizhoozi Center, Inc.

NCS National Comorbidity Study

NIAAA National Institute on Alcohol

Abuse and Alcoholism

NIDA National Institute on Drug Abuse

NIH National Institutes of Health

NIMH National Institute of Mental

Health

NLAES National Longitudinal Alcohol

Epidemiologic Study

NMHA National Mental Health

Association

NRC National Research Council

NTIES National Treatment Improvement

Evaluation Study

OCD obsessive­compulsive disorder

ONDCP Office of National Drug Control

Policy

PCP phencyclidine

PD personality disorder

PG pathological gambling

PIC Practice Improvement

Collaboratives

PPC patient placement criteria

PRISM Psychiatric Research Interview

for Substance and Mental

Disorders

PTSD posttraumatic stress disorder

Acronyms 311
RPT Relapse Prevention Therapy

SADAP State Alcohol and Drug Abuse

Profiles

SAMHSA Substance Abuse and Mental

Health Services Administration

SAMI substance abusing mentally ill

SAMM Substance Abuse Management

Module

SCID Structured Clinical Interview for

Diagnosis

SDS Symptom Distress Scale

SMI severely mentally ill

SOGS South Oaks Gambling Screen

SPMI serious and persistent mental

illness

SSI­SA Simple Screening Instrument for

Substance Abuse

SSRI	 selective serotonin reuptake

inhibitor (a type of antidepressant)

STD sexually transmitted disease

STEMSS Support Together for

Emotional/Mental Serenity and

Sobriety

STP Short­Term Program

TC therapeutic community

TIP Treatment Improvement Protocol

TREM Trauma Recovery and

Empowerment Model

UFDS Uniform Facility Data Set

URICA University of Rhode Island

Change Assessment Scale

WFIR Women’s Forensic Intensive

Recovery

312	 Acronyms
Appendix C:

Glossary of Terms

Note to the reader: The definitions of many of these terms have been

taken verbatim from the Diagnostic and Statistical Manual of Mental

Disorders, 4th edition, text revision (DSM­IV­TR) (American Psychiatric

Association 2000). Such definitions have been presented and properly

attributed in the text of this TIP. See appendix B, Acronyms, for

acronym definitions.

Abstinent

Not using substances of abuse at any time.

Acculturated

Mentally and physically in harmony with and connected to the culture in which one lives.

ACT

See Assertive Community Treatment

Acute care

Short­term care provided in intensive care units, brief hospital

stays, and emergency rooms for those who are severely intoxicated

or dangerously ill.

Addiction

Physical dependence on a substance of abuse. Inability to cease use of

a substance without experiencing withdrawal symptoms. Sometimes

used interchangeably with the term substance dependence.

AD/HD

See attention deficit/hyperactivity disorder

Addiction-only services

Programs that by law or regulation, by choice, or for lack of

resources cannot accommodate patients who have psychiatric illnesses that require ongoing treatment, however stable the illness and

however well­functioning the patient.

313
Advanced program

A treatment program that has the capacity

to provide integrated substance abuse and

mental health treatment for clients with

COD. These programs address COD using

an integrated perspective and provide services for both disorders.

Agitation

A restless inability to keep still. Agitation is

most often psychomotor agitation, that is,

having emotional and physical components.

Agitation can be caused by anxiety, overstimulation, or withdrawal from depressants and stimulants.

Anorexia nervosa

A disorder in which the individual refuses

to maintain a minimal normal body weight,

is intensely afraid of gaining weight, and

exhibits a significant disturbance in the

perception of the shape or size of his or her

body.

Antiretroviral combination therapy

Treatment for HIV/AIDS infection that

employs several medications in combination to suppress the HIV virus or delay

both the development of resistant viruses

and the appearance of AIDS symptoms.

Antisocial personality disorder

An illness whose two essential features are:

(1) a pervasive disregard for and violation

of the rights of others and (2) an inability

to form meaningful interpersonal relationships. Deceit and manipulation are important manifestations of antisocial personality

disorder.

Anxiety disorder

An illness whose essential feature is excessive anxiety and worry. The individual with

anxiety disorder finds it difficult to control

the worry, and the anxiety and worry are

accompanied by additional symptoms from

a list that includes restlessness, being easily

fatigued, difficulty concentrating, irritability, muscle tension, and disturbed sleep,

among other signs and symptoms.

Assertive Community Treatment (ACT)

A form of treatment that typically employs

intensive outreach activities, continuous

24­hour responsibility for client’s welfare,

active and continued engagement with

clients, a high intensity of services, as well

as the provision of services by multidisciplinary teams. ACT emphasizes shared

decisionmaking with the client as essential

to the client’s engagement process.

Assessment

A basic assessment consists of gathering

key information and engaging in a process

with the client that enables the counselor to

understand the client’s readiness for

change, problem areas, COD diagnosis,

disabilities, and strengths. An assessment

typically involves a clinical examination of

the functioning and well­being of the client

and includes a number of tests and written

and oral exercises. The COD diagnosis is

established by referral to a psychiatrist or

clinical psychologist. Assessment of the

client with COD is an ongoing process that

should be repeated over time to capture the

changing nature of the client’s status.

Attention deficit/hyperactivity disorder

(AD/HD)

A persistent pattern of inattention and/or

hyperactivity­impulsivity that is more frequently displayed and more serious than is

typically observed in individuals at a comparable level of development.

Basic program

A treatment program with the capacity to

provide treatment for one disorder, but

thatalso screens for other disorders and is

able to access necessary consultations.

Blackout

A blackout consists of a period of amnesia

or memory loss, typically caused by chronic, high­dose substance abuse. The person

later cannot remember the blackout period. Blackouts are most often caused by

sedative­hypnotics such as alcohol and the

benzodiazepines.

314 Glossary of Terms
Borderline personality disorder

An illness whose essential feature is a pervasive pattern of instability of interpersonal relationships, self­image, and affects,

along with marked impulsivity that begins

by early adulthood and is present in a variety of contexts.

Bulimia nervosa

An illness whose essential feature is binge

eating and inappropriate compensatory

methods to prevent weight gain. In addition, the self­evaluation of individuals with

bulimia nervosa is excessively influenced

by body shape and weight.

CAGE questionnaire

A brief alcoholism screening tool asking

subjects about attempts to Cut down on

drinking, Annoyance over others’ criticism

of the subject’s drinking, Guilt related to

drinking, and use of an alcoholic drink as

an Eye opener.

CBT

See cognitive–behavioral therapy

CCISC

See Comprehensive Continuous Integrated

System of Care

CM

See contingency management

COD

See co­occurring disorders

Coerced

Legally forced or compelled.

Cognitive

Pertaining to the mind’s capacity to understand concepts and ideas.

Cognitive–behavioral therapy (CBT)

A therapeutic approach that seeks to modify negative or self­defeating thoughts and

behavior. CBT is aimed at both thought

and behavior change—that is, coping by

thinking differently and coping by acting

differently.

Coke bugs

Slang term for tactile hallucinations (also

called formications) that feel like bugs

crawling on or under the skin. Chronic and

high­dose stimulant abuse can cause these

hallucinations.

Collaboration

In the context of treatment programs, collaboration is distinguished from consultation by the formal quality of the collaborative agreement, such as a memorandum of

understanding or a service contract, which

documents the roles and responsibilities

each party will assume in a continuing relationship.

Combined psychopharmacological

intervention

Treatment episodes in which a client

receives medications both to reduce cravings for substances and to medicate a mental disorder.

Comorbid disorders

See co­occurring disorders

Competency

An ability, capacity, skill, or set of skills.

Comprehensive Continuous Integrated

System of Care (CCISC)

A theoretical method for bringing the mental health and substance abuse treatment

systems (and other systems, potentially)

into an integrated planning process to

develop a comprehensive, integrated system of care. The CCISC is based on an

awareness that co­occurring disorders are

to be expected in clients throughout the

service system.

Concomitant treatment

Treatment of two or more mental or physical disorders at the same time.

Confrontation

A form of interpersonal exchange in which

individuals present to each other their

observations of, and reactions to, behaviors and attitudes that are matters of concern and should be changed. Confrontation

Glossary of Terms 315
presents “reality” to individuals. The goal

of confrontation is feedback on behavior

and the compelling appeal to the client for

personal honesty, truthfulness in dealing

with others, and responsible behavior.

Constricted pupils (pinpoint pupils)

Pupils that are temporarily narrowed or

closed. This is usually a sign of opioid

abuse.

Consultation

In the context of treatment programs, consultation is a traditional type of informal

relationship among treatment providers,

such as a referral or a request for exchanging information.

Contingency management (CM)

An approach to treatment that maintains

that the form or frequency of behavior can

be altered through a planned and organized system of positive and negative consequences. CM assumes that neurobiological

and environmental factors influence substance use behaviors and that the consistent application of reinforcing environmental consequences can change these behaviors.

Continuing care

Care that supports a client’s progress,

monitors his or her condition, and can

respond to a return to substance use or a

return of symptoms of mental disorder. It

is both a process of post­treatment monitoring and a form of treatment itself.

Sometimes referred to as aftercare.

Convulsion

A symptom of a seizure, characterized

by twitching and jerking of the limbs.

A seizure is a sudden episode of uncontrolled electrical activity in the brain. If

the abnormal electrical activity spreads

throughout the brain, the result may be

loss of consciousness and a grand mal

seizure. Seizures may occur as the result of

head injury, infection, cerebrovascular

accidents, withdrawal from sedative­hypnotic drugs, or high doses of stimulants.

Co-occurring disorders (COD)

Refers to co­occurring substance use

(abuse or dependence) and mental disorders. Clients said to have COD have one or

more mental disorders as well as one or

more disorders relating to the use of alcohol and/or other drugs. See dually disordered.

Countertransference

The feelings, reactions, biases, and images

from the past that the clinician may project

onto the client with COD.

Crack

Cocaine (cocaine hydrochloride) that has

been chemically modified so that it will

become a gas vapor when heated at relatively low temperatures. Also called “rock”

cocaine.

Cross-training

The simultaneous provision of material and

training to persons from more than one discipline (for example, to substance abuse

and social work counselors or to substance

abuse counselors and corrections officers).

Cultural competence

The capacity of a service provider or an

organization to understand and work effectively in accordance with the cultural

beliefs and practices of persons from a

given ethnic/racial group. Also includes an

ability to examine and understand nuances

and exercise full cultural empathy.

Cultural destructiveness

Practices or actions through which an individual shows that he or she regards other

cultures as inferior to the dominant culture,

through cultural incapacity and blindness

to more positive attitudes and greater levels

of skill.

Cultural proficiency

The highest level of cultural capacity, which

implies an ability to perceive the nuances of

a culture in depth and a willingness to work

to advance in proficiency through leadership, research, and outreach.

316 Glossary of Terms
Cultural sensitivity

The capacity and willingness of a clinician

or other service provider to be open to

working with issues of culture and diversity.

Culturally competent treatment

Biopsychosocial or other treatment that is

adapted to suit the special cultural beliefs,

practices, and needs of a client.

DDC

See dual diagnosis capable

DDE

See dual diagnosis enhanced

Deficit

In the context of substance abuse treatment, disability, or inability to function

fully.

Detoxification

A clearing of toxins from the body. The

medical and biopsychosocial procedure

that assists a person who is dependent on

one or more substances to withdraw from

dependence on all substances of abuse.

Dilated pupils

Pupils that have become temporarily

enlarged.

Disorder

An illness or a disruption of some mental

or physical process.

Domestic violence

The use of emotional, psychological, sexual,

or physical force by one family member or

intimate partner to control another. Violent

acts include verbal, emotional, and physical

intimidation; destruction of the victim’s

possessions; maiming or killing pets;

threats; forced sex; and slapping, punching,

kicking, choking, burning, stabbing, shooting, and killing victims. Spouses, parents,

stepparents, children, siblings, elderly relatives, and intimate partners may all be targets of domestic violence.

Downers

Slang term for drugs that exert a depressant effect on the central nervous system.

In general, downers are sedative­hypnotic

drugs, such as benzodiazepines and barbiturates.

Dual diagnosis capable (DDC)

Of or pertaining to programs that address

co­occurring mental and substance­related

disorders in their policies and procedures,

assessment, treatment planning, program

content, and discharge planning.

Dual diagnosis enhanced (DDE)

Of or pertaining to programs that have a

higher than average level of integration of

substance abuse and mental health treatment services. These programs are able to

provide primary substance abuse treatment to clients who are, compared with

those treatable in DDC programs, more

symptomatic and/or functionally impaired

as a result of their co­occurring mental disorder.

Dually disordered

Having been diagnosed with two disorders,

for example a substance use disorder and a

mental health disorder.

Dual recovery groups

Therapy groups in which recovery skills

for co­occurring disorders are discussed.

DTs

Delirium tremens, a state of confusion

accompanied by trembling and vivid hallucinations. Symptoms may include restlessness, agitation, trembling, sleeplessness,

rapid heartbeat, and possibly convulsions.

Delirium tremens often occurs in people

with alcohol use disorders after withdrawal

or abstinence from alcohol.

Ecstasy

Slang term for methylenedioxymethamphetamine (MDMA), a member of the

amphetamine family (for example, speed).

At lower doses, MDMA causes distortions

of emotional perceptions. At higher doses,

it causes potent stimulation typical of the

amphetamines.

Glossary of Terms 317
Empirical

Relying on observation or experience rather

than theoretical principles or theory.

Engagement

A client’s commitment to and maintenance

of treatment in all of its forms. A successful

engagement program helps clients view the

treatment facility as an important

resource.

Formal collaboration

Formal collaboration occurs when the

nature of the client’s disabilities requires

more specific information and more complex and targeted intervention. This level

of working relationship ensures that

providers give attention to both mental

health and substance abuse disorders in

the treatment regimen. An example of such

collaboration is an interagency staffing

conference where representatives of both

mental health and substance abuse agencies

take part in the development and implementation of a specific treatment program

for clients with co­occurring disorders.

Focus is placed on the creation of an individualized treatment plan that is implemented under the auspices of one system or

the other. (See also collaboration and service integration.)

Fully integrated program

A treatment program that actively combines substance abuse and mental health

interventions to treat disorders, related

problems, and the whole person more

effectively.

Functional

Pertaining to a person’s ability to carry out

tasks. Also, working, able to work.

Grounding

The use of strategies that soothe and distract the client who is experiencing intense

pain or other strong emotions, helping the

client anchor in the present and in reality.

Grounding techniques direct the mental

focus outward to the external world, rather

than inward toward the self. Also can be

referred to as “centering,” “looking outward,” “distraction,” or “healthy detachment.”

Habilitation

Initial learning and the acquisition of skills

necessary for everyday life.

Hallucinogens

A broad group of drugs that cause distortions of sensory perception. The prototype

hallucinogen is lysergic acid diethylamide

(LSD). LSD can cause potent sensory perceptions, such as visual, auditory, and tactile hallucinations. Related hallucinogens

include peyote and mescaline.

Hepatitis

An inflammation of the liver, with accompanying liver cell damage and risk of

death. Hepatitis may be of limited duration

or a chronic condition. It may be caused by

viral infection, or by chronic exposure to

poisons, chemicals, or drugs of abuse, such

as alcohol.

Ice

Slang term for smokeable methamphetamine. Just as cocaine can be modified

into a smokeable state (crack cocaine),

methamphetamine can be prepared so that

it produces a gas vapor when heated at relatively low temperatures. When smoked,

ice methamphetamine produces an

extremely potent and long­lasting euphoria,

an extended period of high energy and possible agitation, followed by an extended

period of deep depression.

ICM

See Intensive Case Management

Impaired

Hampered or held back from being able to

do some mental or physical task.

Infectious

Able to spread by an agent such as a virus

or bacterium.

Informal collaboration

Informal collaboration ensures that both

318 Glossary of Terms
mental illness and substance abuse problems are sufficiently understood by all participating providers to allow effective

identification, engagement, prevention, and

early intervention. An example of this type

of collaboration is a telephone request for

information or general advice regarding the

origins and clinical course of depression in

a person abusing alcohol or drugs. Discussion of a particular client usually does not

occur, or occurs at a relatively general

level. (See also collaboration, service integration.)

Integrated competencies

The possession of specific attitudes, values,

knowledge, and skills required to provide

appropriate services to individuals with

COD in the context of their actual job and

program setting.

Integrated interventions

Specific treatment strategies or therapeutic

techniques in which interventions for two

or more disorders are combined in a single

session or interaction, or in a series of

interactions or multiple sessions.

Integrated treatment

Any mechanism by which treatment interventions for co­occurring disorders are

combined within the context of a primary

treatment relationship or service setting. It

recognizes the need for a unified treatment

approach to meet the substance abuse,

mental health, and related needs of a

client, and is the preferred model of treatment.

Integration

As defined by NASMHPD and NASADAD

in the context of treatment programs,

denotes relationships among mental health

and substance abuse providers in which

the contributions of professionals in both

fields are moved into a single treatment setting and treatment regimen.

Intensive Case Management (ICM)

A thorough, long­term service to assist

clients with serious mental illness (particularly those with psychiatric and functional

disabilities and a history of not adhering to

prescribed outpatient treatment) by establishing and maintaining linkages with community­based service providers. ICM typically provides referrals to treatment programs, maintains advocacy for clients, provides counseling and crisis intervention,

and assists in a wide variety of other basic

services.

Intermediate program

A treatment program that focuses primarily on one disorder without substantial modification to its usual treatment, but also

with the capacity to explicitly address specific needs of another disorder.

Intersystem linkages

Connections between substance abuse

treatment and mental health systems that

allow collaboration. Necessary because

these are the primary care systems for persons with COD.

Intervention

Encompasses the specific treatment strategies, therapies, or techniques that are used

to treat one or more disorders.

Legal problems

People who abuse substances are at a higher risk for engaging in behaviors that are

high risk and illegal. These behaviors may

result in arrest and other problems with

the criminal justice system. Examples of

such behaviors include driving while intoxicated, writing bad checks to obtain money

for drugs, failure to pay bills and credit

card debts, possession or sale of drugs,

evictions, and drug­related violence.

Locus

A place or a setting for some activity.

Marijuana

The Indian hemp plant cannabis sativa;

also called “pot” and “weed.” The dried

leaves and flowering tops can be smoked or

prepared in a tea or food. Marijuana has

two significant effects. In the person with

Glossary of Terms 319
no tolerance for it, marijuana can produce

distortions of sensory perception, sometimes including hallucinations. Marijuana

also has depressant effects and is partially

cross­tolerant with sedative­hypnotic drugs

such as alcohol. Hashish (or “hash”) is a

combination of the dried resins and compressed flowers of the female plant.

Mental health program

An organized array of services and interventions with a primary focus on treating

mental health disorders, whether providing

acute stabilization or ongoing treatment.

Mental health treatment system

A broad array of services and programs

intended to treat a wide range of mental

health disorders.

MI

See motivational interviewing

Modified Therapeutic Community (MTC)

A therapeutic community whose approach

to treatment adapts the principles and

methods of the therapeutic community to

the circumstances of the COD client. The

MTC employs interventions that have special functions, all of which share community, therapeutic, and educational purposes. All interventions are grouped into four

categories: community enhancement, therapeutic/ educative, community/clinical

management, and vocational.

Mood disorders

Include the depressive disorders (“unipolar

depression”), the bipolar disorders, and

two disorders based on etiology—mood disorder due to a general medical condition

and substance­induced mood disorder.

Motivational interviewing (MI)

A client­centered, directive method for

enhancing intrinsic motivation to change by

exploring and resolving ambivalence.

MTC

See Modified Therapeutic Community

Mutual self-help

An approach to recovery from substance

use disorders that emphasizes personal

responsibility, self­management, and

clients’ helping one another. Such programs apply a broad spectrum of personal

responsibility and peer support principles,

usually including 12­Step methods that prescribe a planned regimen of change.

Nodding out

Slang term for the early stages of depressant­induced sleep. Opioids and sedativehypnotics induce depression of the central

nervous system, causing mental and behavioral activity to become sluggish. As the

nervous system becomes profoundly

depressed, symptoms may range from

sleepiness to coma and death. Typically,

“nodding out” refers to fading in and out

of a sleepy state.

National Mental Health Association

(NMHA)

A policymaking and educational association

that holds workshops and has an annual

conference for clinicians working with persons with mental health problems, including persons with COD. The organization

continues to develop resources, documents,

publications, and a COD­designated section

on its Web site.

Neuroleptic medication

A drug used to treat psychosis, especially

schizophrenia.

NMHA

See National Mental Health Association

Opioid

A type of depressant drug that diminishes

pain and central nervous system activity.

Prescription opioids include morphine,

meperidine (Demerol), methadone, codeine,

and various opioid drugs for coughing and

pain. Illicit opioids include heroin, also

called “smack,” “horse,” and “boy.”

Organization

An entity that provides mental health ser320 Glossary of Terms
vices in two or three service settings (inpatient, residential, or outpatient) and is not

classified as a psychiatric or general hospital or as a residential treatment center.

Outreach strategies

Approaches that actively seek out persons

in a community who may have substance

use disorders and engage them in substance

abuse treatment.

Paranoia

A type of delusion, or false idea, that is

unchanged by reasoned argument or proof

to the contrary. Clinical paranoia involves

the delusion that people or events are in

some way specially related to oneself.

People who are paranoid may believe that

others are talking about them, plotting

devious plans about them, or planning to

hurt them. Paranoia often occurs during

episodes of high­dose chronic stimulant use

and may occur during withdrawal from

sedative­hypnotics such as alcohol.

Paraphernalia

A broad term that describes objects used

during the chemical preparation or use of

drugs. These include syringes, syringe needles, roach clips, and marijuana or crack

pipes.

Pathological gambling

An illness whose essential feature is persistent and recurrent maladaptive gambling

behavior that disrupts personal, family, or

vocational pursuits.

Personality disorders

Rigid, inflexible, and maladaptive behavior

patterns of sufficient severity to cause

internal distress or significant impairment

in functioning. Personality disorders are

enduring and persistent styles of behavior

and thought, rather than rare or unusual

events in someone’s life.

Posttraumatic stress disorder (PTSD)

An illness whose essential feature is the

development of characteristic symptoms following exposure to an extreme traumatic

stressor involving direct personal experience

of an event that involves actual or threatened death or serious injury, or other threat

to one’s physical integrity; or witnessing an

event that involves death, injury, or a threat

to the physical integrity of another person;

or learning about unexpected or violent

death, serious harm, or threat of death or

injury experienced by a family member or

other close friend or relative.

Practice Improvement Collaboratives

Community­based initiatives that link

treatment providers, researchers, and policymakers in order to build a strong foundation to effect action.

Prescribing Onsite Psychiatrist Model

A model for a substance abuse treatment

agency that includes on its staff a psychiatrist who works onsite from 4 to 16 hours a

week. The onsite psychiatrist brings diagnostic, behavioral, and medication services

directly to where the clients are based for

the major part of their treatment.

Prognosis

A clinician’s judgment or estimate of how

well a disorder will respond to treatment.

Program

Currently, substance abuse treatment programs use the Service Delivery Unit (SDU)

as their program definition for the National

Survey of Substance Abuse Treatment

Services. Mental health treatment programs use facility or organization in reporting for the Survey of Mental Health

Organizations, General Hospital Mental

Health Services, and Managed Behavioral

Health Care Organization (SMHD).

Protease inhibitor

Protease is an enzyme used by the HIV to

process new copies of the virus after it has

reproduced. Protease inhibitors are medications used to treat HIV; they interfere

Glossary of Terms 321
with the action of this enzyme, thus interfering with viral reproduction.

Psychopharmacological

Pertaining to medications used to treat

mental illnesses.

Psychosis

A mental disorder that is characterized by

distinct distortions of a person’s mental

capacity, ability to recognize reality, and

relationships to others to such a degree that

it interferes with that person’s ability to

function in everyday life.

Psychosocial

Involving a person’s psychological wellbeing, as well as housing, employment,

family, and other social aspects of life circumstances.

PTSD

See posttraumatic stress disorder

Psychotropic medication

A drug that has an effect on the mind and

sometimes affects behavior as well.

Quadrants of care

A conceptual framework that classifies settings within which clients with COD are

treated. The four quadrants are based on

relative symptom severity, rather than by

diagnosis.

Referral

A process for facilitating client/consumer

access to specialized treatments and services through linkage with, or directing

clients/consumers to, agencies that can

meet their needs. For COD, referrals are

frequently made for detoxification, assessment, special treatment, and medications.

Relapse

A breakdown or setback in a person’s

attempt to change or modify any particular

behavior. An unfolding process in which

the resumption of substance abuse is the

last event in a series of maladaptive

responses to internal or external stressors

or stimuli.

Relapse prevention therapy (RPT)

A variety of interventions designed to teach

individuals who are trying to maintain

health behavior changes how to anticipate

and cope with the problem of relapse. RPT

strategies can be placed in five categories:

Assessment Procedures, Insight/Awareness

Raising Techniques, Coping Skills

Training, Cognitive Strategies, and

Lifestyle Modification.

Remission

A state in which a mental or physical disorder has been overcome or a disease process

halted.

RPT

See relapse prevention therapy

Schizophrenia

A type of psychosis. Persons diagnosed

with schizophrenia are subject to hallucinations occurring in the absence of insight

into their pathological nature, as well as

disorganized speech and grossly disorganized or catatonic behavior. The disorder

lasts for at least 6 months and includes at

least 1 month of active­phase symptoms

including two or more of the following:

delusions, hallucinations, disorganized

speech, grossly disorganized or catatonic

behavior, negative symptoms.

Screening

A formal process of testing to determine

whether a client warrants further attention

at the current time for a particular disorder and, in this context, the possibility of a

co­occurring substance or mental disorder.

The screening process for co­occurring

disorders seeks to answer a “yes” or “no”

question: Does the substance abuse [or

mental health] client being screened show

signs of a possible mental health [or substance abuse] problem? Note that the

screening process does not necessarily identify what kind of problem the person might

have or how serious it might be but determines whether further assessment is

warranted.

322 Glossary of Terms
Service integration

No one set of treatment interventions constitutes integrated treatment. The term

refers to the availability and delivery of a

comprehensive array of appropriate mental health and substance abuse services and

interventions that are identified within a

single treatment plan, coordinated by a single treatment team, and both effective and

responsive to the high degree of severity of

both mental illness and substance abuse

experienced by the client. Under the “no

wrong door” approach, integrated services

should be available, as necessary, through

both mental health and substance abuse

treatment systems. (See also collaboration

and informal collaboration.)

Single State Agencies

Systems that organize statewide services.

Skin abscess

A collection of pus formed as a result of

bacterial infection. Abscesses close to the

skin usually cause inflammation, with redness, increased skin temperature, and tenderness. Abscesses may be caused by

injecting drugs and impurities into the

body.

Slurred speech

A sign of depressant intoxication. When

people consume significant amounts of

sedative­hypnotics and opioids, their

speech may become garbled, mumbled,

and slow.

Stigma

A negative association attached to some

activity or condition. A cause of shame or

embarrassment.

Substance abuse

A maladaptive pattern of substance use

manifested by recurrent and significant

adverse consequences related to the repeated use of substances. Sometimes used interchangeably with the term substance dependence.

Substance abuse treatment program

An organized array of services and interventions with a primary focus on treating

substance use disorders, providing both

acute stabilization and ongoing treatment.

Substance abuse treatment system

A broad array of services organized into

programs intended to treat substance use

disorders. It also includes services organized in accord with a particular treatment

approach or philosophy (e.g., methadone

treatment or therapeutic community).

Substance dependence

A maladaptive pattern of substance use

leading to clinically significant impairment

or distress, as manifested by a need for

increasing amounts of the substance to

achieve intoxication, markedly diminished

effect of the substance with continued use,

the need to continue to take the substance

in order to avoid withdrawal symptoms,

and other serious behavioral effects,

occurring at any time in the same 12­

month period.

Substance use disorders

A class of substance­related disorders that

includes both substance abuse and substance dependence.

Suicidality

A measure or estimate of a person’s likelihood of committing suicide. A high­risk

behavior associated with COD, especially

(although not limited to) serious mood disorders.

System

An organization of a number of different

treatment programs and related services in

order to implement a specific mission and

common goals.

Therapeutic alliance

A type of relationship between client and

clinician in which both are working cooperatively toward the same goals, with

mutual respect and understanding; also

called “helping alliance.” The bond of

Glossary of Terms 323
trust formed between client and clinician

during therapeutic work that makes healing possible.

Therapeutic community (TC)

A social environment or residential treatment setting in which the social and group

process is harnessed with therapeutic

intent. The TC promotes abstinence from

alcohol and illicit drug use, and seeks to

decrease antisocial behavior and to effect a

global change in lifestyle, including attitudes and values. The TC employs the

community itself as the agent of healing.

The TC views drug abuse as a disorder of

the whole person, reflecting problems in

conduct, attitudes, moods, values, and

emotional management. Treatment focuses

on drug abstinence, coupled with social

and psychological change that requires a

multidimensional effort involving intensive

mutual self­help typically in a residential

setting.

Toxicity

Poisonous nature; poisonous quality.

Transference

The feelings, reactions, biases, and images

from the past that the client with COD may

project onto the clinician.

Trauma

Violent mental or physical harm to a person, damage to an organ, etc.

Treatment

Substance abuse treatment is an organized

array of services and interventions with a

primary focus on treating substance abuse

disorders. For the Treatment Episode Data

Set, the Center for Substance Abuse

Treatment defines treatment to include the

following general categories: hospital, shortand long­term residential, and outpatient.

Mental health treatment is an organized

array of services and interventions with a

primary focus on treating mental disorders,

whether providing acute stabilization or

ongoing treatment. These programs may

exist in a variety of settings, such as traditional outpatient mental health centers

(including outpatient clinics and psychosocial rehabilitation programs) or more intensive inpatient treatment units.

Treatment retention

Keeping clients involved in treatment activities and receiving required services.

Tremor

An involuntary and rhythmic movement in

the muscles, most often in the hands, feet,

jaw, tongue, or head. Tremors may be

caused by stimulants such as

amphetamines and caffeine, as well as by

withdrawal from depressants.

TC

See therapeutic community

Unsteady gait

Crooked, meandering, and uncoordinated

walk, typical of alcohol­impaired people.

Uppers

Slang term used to describe drugs that

have a stimulating effect on the central nervous system. Examples include cocaine,

caffeine, and amphetamines.

Wraparound services

Aspects of a treatment program that

address difficult­to­treat problems, such as

finding childcare while in treatment,

arranging for proper housing, and finding

employment.

324 Glossary of Terms
Appendix D:

Specific Mental

Disorders: Additional

Guidance for the

Counselor

In This

Appendix...

Suicidality

Nicotine Dependency

Personality Disorders

(Overview)

Borderline Personality

Disorder

Antisocial Personality

Disorder

Mood and Anxiety

Disorders

Schizophrenia and

Other Psychotic

Disorders

Attention Deficit/

Hyperactivity

Disorder (AD/HD)

Posttraumatic Stress

Disorder

Eating Disorders

Pathological Gambling

Overview

While substance abuse treatment counselors do not always have the

advantage of an accurate diagnosis of every disorder for each of their

clients with co­occurring disorders (COD), the consensus panel believes

it is useful to have a working knowledge of the most common disorders

seen in substance abuse treatment settings. In cases in which a diagnosis

has not been made, the counselor may be able to detect a pattern of

behavior that suggests further assessment is needed. For clients currently receiving care, the counselor’s appreciation of the features and issues

associated with each known disorder may improve coordination and

mutual understanding between substance abuse treatment services and

the mental health providers. Moreover, some knowledge of the disorder

also will help the counselor understand the role of addiction within the

framework of the client’s experience and to see how the client’s disorders

are interrelated. This understanding may be helpful in relapse prevention. In addition, a general appreciation of the features of the disorder

will help the counselor adapt the treatment strategy in meaningful ways

that are more likely to be effective for the particular client. The consensus panel also acknowledges that people with COD may have multiple

combinations of the various mental disorders presented in this appendix

(e.g., a person with a substance use disorder, schizophrenia, and a

pathological gambling problem). However, for purposes of clarity and

brevity the panel chose to focus the discussion on the main disorders and

not explore the multitude of possible combinations.

Known diagnoses should be documented. Such records will help the

treatment agency gain a better understanding of this aspect of client

demographics. If the substance abuse treatment agency seeks supplemental funding for its work with clients who have COD, it will be helpful, if not essential, to report the number and profile of such clients.

Chapter 8 cites the diagnostic criteria used to identify many mental disorders by the standard diagnostic tool for professionals, Diagnostic and

Statistical Manual of Mental Disorders, 4th Edition, Text Revision

325
(DSM­IV­TR) (American Psychiatric

Association [APA] 2000). These criteria are not

duplicated in this appendix.

The disorders in this chapter are discussed

mainly within the following framework of topics: 

• Description of the disorder

• Differential Diagnosis for the disorder,

including how to distinguish this mental disorder from substance­related disorders or

medical conditions that present in a similar

way

• Prevalence

• Substance Use Among People With This

Disorder

• Key Issues and Concerns that arise in working with clients who have this disorder

• Strategies, Tools, and Techniques, including

those relevant to engagement, assessment,

crisis stabilization, short­term care and treatment, and longer term care

Case studies are presented when illustrative

information is useful to the counselor. See

appendix F for medications commonly used to

treat various disorders and observations on

appropriate management of pharmacology with

clients who have substance use disorders.

Readers should also consult the introduction to

chapter 8 for an overview of the aims and limitations of both chapter 8 and this appendix.

Suicidality

Description

Though not a DSM­IV diagnosed mental disorder, per se, suicidality is a high­risk behavior

associated with COD, especially serious mood

disorders. Suicide is a complex behavior usually caused by a combination of factors.

Research shows that most people who kill

themselves have a diagnosable mental or substance use disorder, or both, and that the

majority of them have depressive illness.

Studies indicate that the most promising way

to prevent suicide and suicidal behavior is

through the early recognition and treatment of

substance abuse and mental illnesses, especially depression (U.S. Public Health Service

1999). A wide range of self­harm and severely

negative feelings and beliefs about the self can

be induced or exacerbated by substance use.

As a result, suicidal ideations, intentions, and

behaviors can be potentially lethal complications of substance use disorders, especially for

clients with co­occurring mental disorders.

Self­harm, often called parasuicide, can be

expressed in a less extreme form than suicide,

such as self­cutting, self­burning, and other

self­mutilation behaviors. Poussaint and

Alexander (2000) include “victim­precipitated

homicide” as a form of suicidal behavior and

recognize that drug and alcohol abuse often

play a part in such tragic events. Researchers

von der Stein and Podoll (1999) found that

self­cutting acts were not accompanied by

frank suicidal ideation in 18 percent of 100

male clients with alcoholism hospitalized for

detoxification.

Differential Diagnosis

Suicide or suicide attempts can be the result of

any substance use or mental disorder; however,

suicide is more common in some disorders and

more likely to be lethal with particular disorders. Acute suicidal planning or behavior

requires immediate intervention; sorting out

the differential diagnosis can occur later, once

the client is safe. Note that being suicidal does

not, in itself, mean that the person has an independent mental disorder.

Prevalence

A recent report from the Centers for Disease

Control and Prevention’s National Center for

Health Statistics indicates that in 2002, suicide

was the eleventh leading cause of death for all

Americans and the third leading cause of death

for people ages 15 to 24 (Kochanek and Smith

2004). Males are four times more likely to die

of suicide than are females; however, females

are more likely to attempt suicide than are

males (U.S. Public Health Service 1999). There

326 Specific Mental Disorders: Additional Guidance for the Counselor
are an estimated 16 attempted suicides for each

completed suicide. The ratio is lower in women

and youth and higher in men and the elderly.

Women and youth try more often and with less

success than men; men and the elderly succeed

more frequently. In recent years, rates for

young adults have soared. Significantly, 50 percent of people who commit suicide have alcohol

in their blood (U.S. Public Health Service

1999).

Suicide rates increase with age and are highest

among Caucasian males aged 65 and older.

Older suicide victims are likely to have lived

alone, have been widowed, and have had a

physical illness (U.S. Public Health Service

1999). Other population groups also have elevated rates of suicide. Many communities of

American Indians and Alaska Natives have elevated suicide rates. Between 1980 and 1996,

the rate of suicide among African­American

males ages 15–19 increased 105 percent (U.S.

Public Health Service 1999).

Risk factors

It has been estimated that “25 to 30 percent of

ambulatory clients in general medical practices

have a diagnosable psychiatric condition, and a

further 10 to 15 percent of people suffering

from major psychiatric illnesses such as affective disorder, schizophrenia, and alcoholism

will end their lives by suicide” (Blumenthal

1988, p. 937). Suicide rates are particularly

high among persons with the following mental

disorders (Blumenthal 1988, pp. 944–946):

• Bipolar disorder, particularly at the time of

the switch from depression to mania or vice

versa (as high as 20 percent)

• Schizophrenia—15 percent end life by suicide

• Antisocial personality disorder—5 percent

die by suicide and as many as 46 percent

attempt it

• Borderline personality disorder—5 to 10 percent eventually commit suicide, though they

may also engage in self­destructive behavior

without lethal intent

• Major depression—6 percent

• Substance­induced depression—7 percent

Suicide is also more likely among those with the

personality traits of impulsivity, hopelessness,

or cognitive rigidity (Blumenthal 1988).

Substance use disorders alone increase suicidality (Inskip et al. 1998), and rates of suicide

among persons with the above mental disorders

are even higher (roughly doubled) if co­occurring substance use disorders are present. In

particular, there is a heightened risk of suicide

when relapse occurs after a substantial period

of abstinence—especially if there is concurrent

financial or psychosocial loss.

Suicidality is a

high­risk behavior

associated with

COD, especially

serious mood

disorders.
 

Suicidality and chronic 

medical illness

The presence of a chronic medical illness also is

a major risk factor, possibly by causing depression or by producing an organic disorder.

Individuals at particular risk include people

with epilepsy (who have a suicide rate of four

times that of the population as a whole), people

with cancer, people with peptic ulcers (probably because of the association of alcoholism

with the formation of these ulcers), clients

undergoing renal dialysis, people with

Huntington’s chorea (their suicide rate is six

times greater), and

people with AIDS. It

appears that “severe

or incapacitating

medical status when

associated with

depression, alcoholism, organicity,

and neurological

impairment are

important contributing factors leading to

diminished judgment

and increased impulsivity in medically ill
 

clients” (Blumenthal

1988, p. 951).
 

Specific Mental Disorders: Additional Guidance for the Counselor 327
Suicidality and family history

A family history of suicide is a significant risk

factor, and there is some evidence that biological factors, such as reduced serotonergic function, contribute to a likelihood of violence

against oneself or others (Blumenthal 1988).

Substance Use Among Suicidal

Persons

Alcohol and other drug abuse is a major risk

factor in suicide, both for those with co­occurring mental disorders and for the general population. Alcohol abuse is associated with 25 to 50

percent of suicides; between 5 and 27 percent

of all deaths of people with substance use disorders are caused by suicide, with the lifetime

risk for suicide estimated to be 15 percent

(Blumenthal 1988). There is a particularly

strong relationship between substance abuse

and suicide among young people. One study

found that as many as 70 percent of adolescent

suicide victims had alcohol or substance abuse

problems. For people with substance use disorders, the incidence of suicide is 20 times greater

than the general population (Blumenthal 1988).

Comorbidity of alcoholism and depression

increases suicide risk (Clark and Fawcett

1992), perhaps because these agents exacerbate personality

and cognitive problems, and add to

environmental

stressors. Alcohol

also can impair cognitive functioning

(Rogers 1992).

Using alcohol in

attempts to relieve

depression, anxiety,

and fear often creates more depression and psychological distress, an

effect labeled alcohol myopia (Steele

and Josephs 1990).

Alcohol myopia

involves narrowing or impaired perception

that interferes with inferential thought and

makes one “the captive of an impoverished

version of reality in which the breadth,

depth, and time line of our understanding is

constrained” (Steele and Josephs 1990, p. 923).

Thus, the link between alcohol use and suicide

goes beyond the pharmacological and interpersonal effects. The association also may be a

function of the capacity of alcohol to restrict

attention to immediate situations, inhibit the

ability to solve current problems, and limit

hope for the future (Rogers 1992). “Alcohol

and substance use and abuse exacerbate other

environmental problems and lessen the ability

to cope” (Westefeld et al. 2000, p. 453).

All substance	 

abuse treatment	 

clients should

receive at least a

brief screening

for suicide.

Key Issues and Concerns

The following are key elements of effective suicide prevention.

• All substance abuse treatment clients should

receive at least a basic screening for suicidality. All substance abuse treatment professionals should know how to conduct at least basic

screening and triage.

• The counselor should know his or her own

skills and limitations in engaging, screening,

assessing, and intervening with suicidal

clients. Work out these issues before an emergency.

• Providers are advised to develop clear

answers to the following questions: Do you or

your agency have the knowledge, tools, skills,

and personnel for crisis stabilization and/or

ongoing work with suicidal clients? How suicidal can clients be and still be retained in

your practice or agency? What about suicidality that emerges later in treatment or in

conjunction with a relapse?

• The counselor should know what immediate

onsite and offsite resources are available to

help with someone identified as suicidal.

• Establish standardized protocols and staff

training around suicide screening, assessment, intervention, and/or triage: (1) Who

asks? (2) What is asked? (3) When is this

328 Specific Mental Disorders: Additional Guidance for the Counselor
done? (4) Where does this take place? (5)

How are findings documented? (6) What is

done with the results?

• Suicide “contracts” are written statements in

which the person who is suicidal states that

he will not kill himself, but rather call for

help, go to an emergency room (ER), etc., if

he becomes suicidal. These contracts are not

effective as the sole intervention for a client

who is suicidal. While such contracts often

help to make the client and therapist less

anxious about a suicidal condition, studies

have never shown these contracts to be effective at preventing suicide. What good contracts really do is help to focus on the key

elements that are most likely to keep clients

safe, such as agreeing to remove the means a

client is most likely to use to commit suicide.

Strategies, Tools, and

Techniques

Engagement

It is possible, though uncommon, for people

with suicidality as their primary complaint to

present to substance abuse treatment professionals; it is more likely for them to go to mental health agencies or ERs. Nonetheless, substance abuse treatment counselors should be

prepared to detect suicidality. During the

course of substance abuse assessment, the suicidal client may appear withdrawn, depressed,

or even angry or agitated. It is important to

inquire about these symptoms as they appear.

For example

• “You know, you seem to be pretty down.

How depressed are you?”

• The issue may arise in response to general

questions: “Crack? No, I don’t use that much

any more. I get really down when I’m coming

off it.” The counselor might then ask, “How

down have you gotten? Were you ever suicidal? How are you doing now?”

At issue is the principle that the suicidal client

is more likely to engage with the counselor and

reveal his or her suicidality if the counselor

responds to clues given by the client and

inquires sensitively about them. To say to an

agitated client, “You seem pretty nervous and

uncomfortable—is there something I can do to

help?” opens a door to further assessment.

Screening and assessment

Screening

All substance abuse treatment clients should

receive at least a brief screening for suicide,

such as: “In the past, have you ever been suicidal or made a suicide attempt? Do you have

any of those feelings now?” All substance abuse

treatment staff should be able to screen for suicidality and basic mental disorders. It is

expected that those at the intermediate or

advanced levels of COD competence will have

additional knowledge and skills.

Risk assessment

No generally accepted and standardized suicide

assessment has been shown to be reliable and

valid, but most established suicide assessments

contain similar elements. A particularly easyto­use method has been developed by the QPR

Institute for Suicide Prevention. Further information and training is available at their Web

site (http://www.qprinstitute.com/).

The QPR Institute’s risk assessment interview

is designed to elicit information about the individual’s current risk of suicide, which then can

be used to match the level of care with the level

of risk (Quinnett and Bratcher 1996). The

authors note that “client answers to an initial

seven questions provide the database for clinical decision making, while the client’s level of

commitment to a safety/treatment management

plan determines the level of care, e.g., outpatient, inpatient, evaluation for involuntary

admission.” See Figure D­1 (p. 330).

While the entire protocol includes 13 questions,

the seven questions in Figure D­1 provide rich

data that provide a basis for making clinical

decisions.

Specific Mental Disorders: Additional Guidance for the Counselor 329
Figure D­1

Key Questions in a Suicide Risk Review

What is wrong? 

• Personal narrative about how bad things are and the nature of the problem(s)

• Personal construction of reasons for suicide

• Personal measure of psychological pain and suffering

Why now?

• Elements of the current crisis

• History of real or imagined losses or rejections

• Sudden and unacceptable changes in life circumstances; for example, the client just received a

serious or terminal diagnosis, relapse, onset of possible symptoms (e.g., sleeplessness)

With what?

• The means of suicide under consideration

• Access to the means selected

Where and when?

• Possible location and timing of a suicide attempt

• Degree of planning

• Possible anniversary phenomena

When and with what in the past?

• Past history of suicidal behavior

• Past history of intense suicidal ideation and/or planning

• Whether rescue was avoided

• Timing of past attempts

• Social response to past attempts

• Potential protective factors (reasons for living)

• Comparison of current method versus old method

Who’s involved?

• Others who may know or be involved

• Persons who may or may not be helpful in managing the client

• Names of potentially helpful third parties

• Possible presence of a suicide pact or murder­suicide plan

Why not now?

• One or more protective factors (reasons for living)

• Spiritual or religious prohibitions

330 Specific Mental Disorders: Additional Guidance for the Counselor
Figure D­1 (continued)

Key Questions in a Suicide Risk Review

Source: Quinnett and Bratcher 1996.

• Duties to others or pets

• Residual tasks to be completed before the attempt; for example, making out a will

Instead of the common “no­suicide” contracts

(e.g., “I will go to the ER before taking an

overdose”), this protocol recommends a more

complete informed consent, safety, and risk

management process that requires the client’s

consent to six key elements. These are

• To remain clean and sober

• To follow medical advice

• To see to the removal of the means of suicide

• To commit to personal safety

• To seek help in case of emergency

• To follow through on referral and/or treatment (Quinnett and Bratcher 1996)

By using this evaluation format or other suicide

evaluation tools, the clinician needs to determine whether the risk of imminent suicide is

mild, moderate, or high. The clinician must

also determine to what degree the client is willing and able to follow through with a set of

interventions to keep safe.

Using many of the same indicators, counselors

should also be prepared to probe the client’s

likelihood of inflicting harm on another person.

Specifically

• On a scale of 0 to 10, with 0 meaning “not

likely at all,” how likely are you to harm this

person in the next week?

• Do you have a plan for how you would do

this?

• Would you be willing to agree not to harm

this person during the next week?

• Would you be willing to agree to tell someone

before you do this?

• How confident are you that you can remain

sober over the next week? What can you do

to increase the chances you will remain

sober? (e.g., use of 12­Step meetings, supports, or treatment).

Screening personnel should also assess whether

suicidal feelings are transitory or reflect a

chronic condition. Factors that may predispose

a client toward suicide and should be considered in client evaluation can be seen in “Risk

Factors” above.

Documentation

In today’s managed care environment, intakes

are often preprinted with yes/no or other checkoff items. For example, some State versions of

the Addiction Severity Index (ASI) may include

only whether the client has ever had psychiatric

care (yes/no) and whether the client is on psychiatric medications (yes/no) or some other abbreviated psychiatric inventory. As noted, it is the

view of the consensus panel that because suicidality is common in the substance abuse treatment population, all substance abuse treatment

clients should receive at least a brief screening

for suicide. If the screen is positive, the client

should receive a more thorough assessment as

discussed previously. Further screening/assessment should be documented to protect both the

client and the counselor. This means writing

information on evaluation forms or making

additional notes, even if suicide­related items

are not included on the form used.

Crisis stabilization

The first steps in suicide intervention, and thus

crisis stabilization, are contained in the process

Specific Mental Disorders: Additional Guidance for the Counselor 331
of a good engagement and evaluation. Asking

suicide­related questions, exploring the context

of those impulses, evaluating support systems,

considering the lethality of means, and assessing the client’s motivation to seek help are in

themselves an intervention. Such an interview

will often elicit the client’s own insight and

problem solving and may result in a decrease in

suicidal impulses.

If, however, the client experiences little or no

relief after this process, then it is clear that

psychiatric intervention is required. This is

especially true if it emerges that the client has a

co­occurring mental disorder or medical disorder in which the risk of suicide is elevated (see

“Risk Factors” above) or if the client has a history of suicide attempts. If either or both is

true, arrangements should be made for transfer to a facility that is capable of more intensive

psychiatric evaluation and treatment.

Emergency procedures should be in place so

the counselor can accomplish this transfer even

when a psychiatrist or clinical supervisor/director are not available. Once the client is stabilized and is safe to return to a less restrictive

setting, he or she should return to the program.

Short­term care and 

treatment

Treatment for the client who is suicidal should

include supportive care aimed at helping the

client vent feelings, discover alternatives,

improve relationships, change negative thinking, and focus on the future (Blumenthal 1988).

The clinician should be caring and supportive.

The seriously suicidal client should have someone to contact 24 hours a day, and frequent

telephone contact between the client and the

contact person usually is indicated.

Management of a client who is suicidal “usually

requires the assistance of a psychiatric consultant and is clearly indicated for all clients who

have a serious plan for suicide or who have

made an attempt” (Blumenthal 1988, p. 958).

At a minimum, “consultation with a psychiatric

colleague who has specialty training in the diagnosis of mental illness is often indicated and

may be particularly helpful in the assessment

and management of acutely suicidal persons”

(Blumenthal 1988, p. 959). The client should

be evaluated by a psychiatrist onsite immediately, or a case manager or counselor should

escort the client to emergency psychiatric services. Where available, mobile crisis service,

which includes a psychiatrist, is another quick

response resource for the management of the

client who is suicidal.

Case management

Interventions should seek to increase support

available to the client from the family and community, and should provide immediate interventions, including medication to stabilize the

client’s mental state, if needed.

Psychoeducation

Families and individuals often benefit from

education about depression and suicidality,

including warning signs, resources for help,

and the importance of addressing this problem.

Education often provides individuals with a

sense of hope and realistic expectations. Many

individuals will have passive suicidal ideation

at one point in their lives. Some individuals will

feel reassured to know their feelings are not

uncommon and be more willing to share their

feelings about their thoughts.

Adapting mental health/substance

abuse treatment approaches to

specific disorder subtypes

The co­occurrence of substance abuse and suicidal thoughts increases the risk of suicide and

requires clinicians to be more active in their

management of the problem. People with

chronic substance use disorders may need to

undergo detoxification and may have cognitive

limitations secondary to chronic usage.

Longer term care

Suicidality is not in itself a disease; rather, it is

a short­term, acute, and potentially lethal

behavior or set of behaviors. Longer term

treatment issues for a client who has been suici332 Specific Mental Disorders: Additional Guidance for the Counselor
dal focus on long­term treatment strategies for

COD or on other risk factors that have culminated in a suicidal event. In this case, treatment becomes long­term prevention. Some persons who are chronically suicidal need special

programs that can handle this chronic behavior

(American Society of Addiction Medicine 2001).

Among clients with dependence on alcohol,

“suicide frequently occurs late in the disease,

often in relation to rejection or some interpersonal loss as well as to the onset of medical

complications of the illness” (Blumenthal 1988,

p. 945). Particular attention should be given to

people with long­term dependence on alcohol

who are developing medical symptoms, who are

experiencing a personal loss or crisis, or who

have had a relapse. It is wise to check for suicidal ideation regularly as it can recur. Since

relapse is far and away the most dangerous suicide risk in long­term substance abuse treatment clients, the consensus panel recommends

a solid long­term recovery plan as the best

approach to suicide prevention. In persons

with serious and persistent mental disorders,

such as bipolar disorder, long­term medication

compliance is a key element in preventing suicide. Just as essential as medication and medication compliance, however, is the need to

rebuild a sense of hope in the future and

engender the belief that recovery from cooccurring disorders is possible and that one has

a sense of purpose, value, empowerment, and

role in one’s own recovery.

Tobacco dependence is the most

common substance

use disorder in the

United States.

Nicotine Dependence

Tobacco dependence is the most common substance use disorder in the United States, and

cigarette smoking is the primary preventable

cause of disease and deaths in the United

States. Smoking causes approximately 450,000

premature deaths among people who use tobacco and an additional 50,000 deaths in nonsmokers from exposure to environmental

tobacco smoke (U.S. Public Health Service,

Office of the Surgeon General 2004; Ziedonis

and Fiester 2003).

Tobacco dependence

is present in most

clients in mental

health and addiction

treatment settings.

Individuals with

behavioral health disorders spend about

$214 billion annually

on tobacco, and

account for 44 percent of all cigarettes

smoked in the United

States (Lasser et al.

2000). More people

with alcohol use disorders die from smoking­related diseases

than from alcoholrelated diseases (Hurt

et al. 1996). Smoking is also linked to depression and substance use disorders. Research

repeatedly has shown that, compared with the

general population, people who smoke are

more likely to abuse substances, and people

who abuse substances are more likely to smoke

cigarettes. Those who abuse alcohol are two to

three times more likely to smoke than the general population (Anthony and EcheagarayWagner 2000; Gilbert 1995), and up to seven

times more likely to smoke heavily (Collins and

Marks 1995). There is no simple reason why so

many clients in mental health or substance

abuse treatment smoke. As with other addictive

disorders, it is likely a combination of complex

biological and psychosocial factors (Ziedonis

and Fiester 2003).

Nicotine dependence was first included as a

substance use disorder in the Diagnostic and

Statistical Manual of Mental Disorders, Third

Edition (DSM­III) in 1980. The diagnostic criteria for dependence are the same as other substance use disorders. Of note, unlike all other

substances, the DSM only recognizes nicotine

dependence (there is no diagnosis of nicotine

abuse) because most individuals transition

quickly and directly from use to dependence

and meet criteria of tolerance and withdrawal.

The nicotine withdrawal syndrome develops

Specific Mental Disorders: Additional Guidance for the Counselor 333
after abrupt cessation of or a reduction in the

use of nicotine products and is accompanied by

four of the following signs and symptoms: (1)

dysphoria or depressed mood; (2) insomnia; (3)

irritability, frustration, or anger; (4) anxiety;

(5) difficulty concentrating; (6) restlessness or

impatience; (7) decreased heart rate; and (8)

increased appetite or weight gain (APA 2000, p.

266). The withdrawal symptoms also must

cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Although nicotine is thought to be the primary

addictive component in tobacco, it is important

to remember that not all forms of nicotine are

equivalent. The pharmacology and potential

for addiction to nicotine is dependent on its

route of entry into the body. Smoking is an

extremely efficient route of administration, and

delivers the fastest and highest­spiking arterial

dose of nicotine. Nicotine delivery from smoking produces levels of nicotine in the body that

are many times higher than those achieved with

use of nicotine replacement therapies (NRT).

Therefore, NRT products do not replicate the

perceived effect of smoking.

NRT has been found to be safe in cardiovascular disease and safe in persons who use it while

continuing to smoke. Several forms are available without prescription (patches,

gum, lozenge), since

nicotine is not a carcinogen and there is

little abuse potential

for nicotine when it

is administered in

forms other than

smoking. Nicotine

has a pH of 8, making oral absorption

poor. NRT products

rely on administration through the

skin, or buccal

(cheek) or nasal

mucosa, and are

buffered to increase

alkalinity and absorption. Nicotine absorption

in the mouth is markedly reduced when it is

administered with acidic beverages like sodas,

coffee, and juices. Simple instructions not to

use the gum, lozenge, or inhaler in conjunction

with these beverages can greatly increase the

nicotine absorption.

Research has demonstrated that the vast

majority of harm associated with cigarettes is

attributable to the byproducts of smoking

rather than to the effects of nicotine (Slade

1999). In addition to nicotine, unprocessed

tobacco smoke includes more than 2,500 compounds, and when manufactured additives and

other compounds are taken into account, about

4,000 compounds are present (U.S.

Department of Health and Human Services

1988). Smoking is the cause of 90 percent of all

lung cancers and nearly all cases of chronic

obstructive pulmonary disease, and is associated with a two times greater risk of death from

stroke and coronary heart disease. It is also

associated with an increased incidence of cancer at a number of other sites, including the

larynx, oral cavity, esophagus, cervix, bladder,

pancreas, and kidney, and is associated with

complications of pregnancy and negative effects

on the fetus, including low birth weight

(Ziedonis and Fiester 2003; U.S. Public Health

Service Office of the Surgeon General 2004).

Why do individuals with mental illness or

addiction die? Most die of smoking­caused diseases, including cardiac and pulmonary problems, infections, and cancer. Among people

who are addicted to narcotics who are in substance abuse treatment, the death rate of smokers is four times that of nonsmokers (Hser et al.

1994). Among people who are in recovery for

alcohol abuse who die, 51 percent of mortality

is attributed to smoking­related illness, and at

20­year followup the cumulative mortality was

48 percent versus 19 percent expected if a person never smoked (Hurt et al. 1994).

More than two	 

thirds of people

who abuse drugs

smoke tobacco

regularly.	 

Differential Diagnosis

Unsuccessful quit attempts, difficulty controlling use, and previous withdrawal symptoms

during abstinence are criteria for nicotine

334 Specific Mental Disorders: Additional Guidance for the Counselor
dependence in both the DSM­IV (APA 1994)

and the ICD­10 (World Health Organization

1992). These sources provide useful descriptions of clinically observed phenomena, and

clinicians are advised to familiarize themselves

with diagnostic criteria and withdrawal symptoms (see Figure D­2, p. 341). However, unlike

other mental disorders, tobacco dependence

diagnostic criteria are rarely used in clinical or

research settings. Instead, tobacco dependence

is usually conceptualized dimensionally rather

than categorically. It should be noted that categorical diagnostic schemes based on DSM criteria are not highly correlated with dimensional

assessments, such as the Fagerstrom Test for

Nicotine Dependence (Moolchan et al. 2002).

Differential diagnosis is a less pressing clinical

issue with tobacco dependence than with other

substance use and mental disorders.

Approximately 80 percent of all people who

smoke, and virtually all people who smoke

daily, are nicotine dependent. DSM­IV diagnostic criteria are identical to those for other

substance use disorders, although DSM does

not recognize Nicotine Abuse as a diagnostic

category.

Prevalence

Although tobacco dependence is the most common substance use disorder, there are subgroups of individuals with particularly high

rates of tobacco dependence. Individuals with

mental illness and other substance use disorders are the most common subgroup; however,

other important subgroups are known. The

prevalence of cigarette smoking is higher at

lower socioeconomic levels. Slightly more males

than females smoke, although more males than

females are successful in stopping smoking.

There is evidence that the number of cigarettes

smoked per person is increasing, leaving a

more hard core and, potentially, more dependent group of people who smoke. There has

also been a recent increase in the rate of smoking among adolescents, particularly in the number of teenage girls smoking. This increased

smoking rate among adolescents is particularly

alarming, as people who smoke typically start

smoking at an early age, with more than 60

percent beginning by age 14, and nearly all by

age 18 (Ziedonis and Fiester 2003).

Tobacco Dependence Among

Individuals With Another

Substance Use Disorder

Rates of smoking in people with substance use

disorders consistently have been shown to be

three to four times higher than in the general

population (Berger 1972; Richter et al. 2000;

Stark and Campbell 1993b), with heavier

smoking linked to increased drug or alcohol

severity (Hughes 1996; Sussman 2002). More

than two thirds of people who abuse drugs

smoke tobacco regularly, a rate double that of

the rest of the population (Zickler 2000).

An 80 to 90 percent rate of smoking has been

found in persons with active alcoholism (Patten

et al. 1996). Similar results have been found in

people who use illicit drugs, with recent studies

finding smoking rates as high as 90 percent

among outpatient substance abuse clients

(Clarke et al. 2001; Clemney et al. 1997; Stark

and Campbell 1993b). Heavy smoking is particularly linked with drinking, with 72 percent of

people in treatment for alcohol use disorders

smoking heavily, versus 9 percent of the general population (Hughes 1995). Smoking also has

been shown to be a predictor of greater problem severity and poorer treatment response

(Krejci et al. 2003).

People who smoke and have a history of an

alcohol problem find nicotine more reinforcing,

and meet more nicotine dependence criteria

and withdrawal symptoms (Hughes et al. 2000;

2002). This may make consideration of pharmacological approaches crucial, although some

clients in recovery from another addiction prefer to quit without medications. There is growing evidence to suggest that many people in

substance abuse treatment are interested in

smoking cessation treatment simultaneously

(Joseph et al. 2002; Saxon et al. 1997),

although there is still some debate as to the best

time for tobacco treatment during substance

Specific Mental Disorders: Additional Guidance for the Counselor 335
abuse treatment. A recent study by Joseph and

colleagues (2003), comparing the timing of

tobacco dependence treatment, showed no difference in number of quit attempts, smoking

abstinence, or use of NRT between those who

received tobacco treatment concurrent with

substance abuse treatment, and tobacco treatment that was delayed for 6 months after initiating intensive substance abuse treatment. The

overall quit rates were comparable to the general population, with about 18 percent achieving abstinence at 1 year.

Surveys have reported that prevalence rates of

smoking in clients in methadone maintenance

programs are between 85 and 98 percent

(Berger 1972; Stark and Campbell 1993a).

Smoking status is predictive of illicit substance

use in methadone programs and increases in a

stepwise fashion from people who do not smoke,

to people who smoke but are nondependent, to

people who smoke heavily (Frosch et al. 2002).

There is a significant positive relationship during treatment between rates of change in heroin

use and rates of change in tobacco use.

Tobacco Dependence Among

Individuals With Mental

Illness

The prevalence of smoking is high among people with all types of mental illnesses, including

schizophrenia (70 to 90 percent), affective disorders (42 to 70 percent), and anxiety disorders, especially agoraphobia and panic disorder. Conversely, there is also evidence that

affective, anxiety, and substance use disorders

may be more common in individuals who

smoke than in those who do not or in those who

have never smoked. The presence of depressive

symptoms during withdrawal is also associated

with failed cessation attempts (APA 1996;

Ziedonis and Fiester 2003).

Smokers with schizophrenia are more likely to

be current smokers (58 to 88 percent versus 23

percent) (Centers for Disease Control and

Prevention 2001; National Institute on Drug

Abuse [NIDA] 1999), to smoke more (Kelly and

McCreadie 1999), and to have ever smoked

daily (De Leon et al. 2002). They also smoke

more “efficiently” by inhaling more deeply and

smoking more of each cigarette (Olincy et al.

1997). People with schizophrenia are less successful in quitting smoking, both in naturalistic

settings (Lasser et al. 2000) and in tobaccodependence treatment trials (Williams and

Hughes 2003). Although smoking rates are elevated among all people with mental disorders,

individuals with schizophrenia are more likely

to smoke than those with other mental disorder

diagnoses (De Leon et al. 2002). In addition,

smokers with schizophrenia are more likely to

experience smoking­related morbidity and

mortality than the general population of smokers (Brown et al. 2000; Dalack et al. 1998). The

effect of tobacco is that medications are metabolized faster and are cleared from the body

more efficiently, causing smokers with

schizophrenia to be prescribed higher medication doses. As a result, these people also experience greater medication side effects such as

tremor (Kelly and McCreadie 1999), rigidity

(Gideon et al. 1994), and possibly tardive dyskinesia (Nilsson et al. 1997).

Key Issues and Concerns

Timing of the quit attempt

A major clinical issue is the timing of the quit

attempt. Should an individual try to quit all

substances at the same time? Clinicians tend to

endorse this strategy for all substances but

tobacco. Although there is debate about the

best time for tobacco treatment for people in

substance abuse treatment, studies suggest that

tobacco treatment does not jeopardize recovery

from other substances and might improve the

outcomes for the other substance use disorder.

Should nicotine dependence treatment be timed

to a specific stage of recovery from a mental

disorder? There are very limited data to guide

this decision other than clinical judgment.

Clinical experience suggests that treating tobacco dependence during outpatient treatment

when mental disorder symptoms are somewhat

336 Specific Mental Disorders: Additional Guidance for the Counselor
stable appears to be an excellent time to target

interventions. Of note, managing tobacco

dependence through forced abstinence because

of environmental tobacco smoke concerns is

necessary, and addressing this issue with

appropriate dosages of NRT is warranted.

Effect of tobacco abstinence

on psychiatric medication

blood levels

Tobacco (not nicotine) is metabolized in the

liver by the P450/1a2 isoenzyme, and tobacco’s

metabolism actually increases the metabolism

rate of certain psychiatric medications such as

haloperidol, fluphenazine, olanzapine, and

clozapine. When an individual stops smoking

tobacco, the liver enzymes P450/1a2 become

less active and metabolize the psychiatric medications at a slower rate. Therefore there will be

an increase in the blood levels of those medications, potentially causing an increase in the

medication’s side effects or other adverse

events, including noncompliance with the medication due to the side effects (APA 1996;

Ziedonis and Fiester 2003).

Effect of tobacco abstinence

on mental disorders

Some clinicians are concerned about whether

tobacco abstinence will worsen mental illness or

jeopardize recovery from other substances.

This is an important area that needs more

research; however, research and clinical experience support the ability of people to quit and

not induce relapses or severe worsening of their

mental illness. The studies to date report that

nicotine dependence treatment for this population is safe and usually well tolerated.

However, there have been reports of some

increases in psychiatric symptoms during the

acute detoxification phase (APA 1996; Ziedonis

and Williams 2003b).

Effect of trying to quit 

smoking on recovery from

other addictions

Until recently, substance abuse treatment clinicians generally have not addressed the issue of

tobacco dependence or provided treatment

largely because of the belief that the added

stress of quitting smoking would jeopardize the

recovery from alcohol or other substances.

Research has not confirmed this belief. One

study evaluated the progress of residents in an

alcoholism treatment facility who were concurrently undergoing a standard smoking cessation

program (i.e., experimental group) (Hurt et al.

1994). A comparison

group of people with

alcohol use disorders

who smoked participated in the same program but without

undergoing the smoking cessation program. One year after

treatment, results

indicated that the

smoking cessation

program had no effect

on abstinence from

alcohol or other

drugs. In addition, 12

percent of the subjects in the experimental group, but

none of the subjects in

the comparison group, had stopped smoking.

Some data suggest that addiction recovery may

facilitate nicotine abstinence. In one study,

clients participating in concurrent treatment

for nicotine addiction during residential treatment for alcohol and other drug abuse

achieved at least a temporary reduction in

smoking and an increased motivation to quit

smoking (Joseph et al. 1990).

The prevalence of

smoking is high

among people with

all types of

mental illnesses.

Following the lead of other health facilities,

many substance abuse treatment facilities are

becoming smoke free, providing a “natural

experiment” on the effectiveness of dual recovSpecific Mental Disorders: Additional Guidance for the Counselor 337
ery programs. Initial evaluations suggest that

no­smoking policies are feasible in this setting

(Martin et al. 1997). However, no outcome

studies have been performed, and additional

research is needed.

Effect of tobacco use on

craving and other drugs

Researchers have found that craving for tobacco appears to increase craving for illicit drugs

among people with substance use disorders who

also smoke tobacco. This relationship suggests

that people who smoke and are in drug treatment programs may be less successful in staying off drugs than people who do not smoke.

Recent research has found that cues that elicited craving for tobacco also elicited craving for the person’s

drug of choice. This

suggests that situations that produce

tobacco craving also

may result in craving for drugs of

abuse (Taylor et al.

2000). The findings

suggest that substance abuse treatment efforts will

benefit from a more

complete understanding of the

interrelationships

between tobacco and

drug craving (Taylor

et al. 2000). In a study among patients on

methadone maintenance, tobacco craving and

heavy smoking appeared to contribute to

increased use of cocaine and heroin (Frosch et

al. 2000). In a study of people with alcohol use

disorders, researchers at Purdue University

concluded that alcohol alone can prompt people who smoke to crave a cigarette. In a study

of rats, Canadian scientists found evidence that

the nicotine in cigarettes can induce a craving

for alcohol (Le et al. 2000) among rats trained

to drink alcohol. Alcohol consumption

increased 20 percent after nicotine exposure

and consumption decreased 30 percent after

mecamylamine exposure. The researchers

hypothesized that nicotine receptors are

involved in alcohol consumption and/or selfadministration (Le et al. 2000).

Nicotine dependence can be

thought of as

a chronic,

relapsing illness.	 

Motivation to quit among

individuals with substance

use or mental disorders

Many people in mental disorder and substance

abuse treatment settings are interested in quitting tobacco, even if the interest is not immediate. In one study 75 percent of substance abuse

treatment inpatients accepted the offer of

smoking cessation treatment (Seidner et al.

1996). In another study, 53 percent of outpatients reported moderate interest in quitting

(Kozlowski et al. 1989). Further, one study of

methadone maintenance patients found that 61

percent planned to quit within 6 months, 57

percent were very interested in an on­site cessation program, and 80 percent were interested

in nicotine replacement products (Clemmey et

al. 1997). Still another study found that 72 to

94 percent of outpatients were not yet ready to

quit (Abrams et al. 1996). In conclusion, there

often is interest in quitting tobacco, but there is

variability in the interest level and there is a

need to provide encouragement and support to

those who are considering quitting smoking.

Realistic expectations:

Tobacco dependence is like

other addictions

Nicotine dependence, like other substance use

disorders, can be thought of as a chronic,

relapsing illness with a course of intermittent

episodes alternating with periods of remission

for most people who smoke. Only about 3 percent of quit attempts without formal treatment

are successful, and in recent years about 30 percent of people who smoke and who want to quit

are seeking treatment. Outcomes for nicotine

dependence treatment vary by the type of treatment and the intensity of treatment, with specif338 Specific Mental Disorders: Additional Guidance for the Counselor
ic reports of 1­year abstinence rates following

treatment ranging from about 15 to 45 percent.

Cessation attempts result in high relapse rates,

with the relapse curve for smoking cessation

paralleling that for opioids. Most individuals

relapse during the first 3 days of withdrawal and

most others will relapse within the first 3 months

(APA 1996; Ziedonis and Fiester 2003). Like any

other substance, individuals can relapse to

tobacco in any stage of recovery.

Strategies, Tools, and

Techniques

Engagement

People entering treatment for substance use or

mental disorders rarely intend to receive treatment for nicotine dependence. They may be

surprised or even annoyed by questions about

their smoking. It is important to initially integrate assessment questions about nicotine

dependence into an overall assessment and

treatment plan, and to be prepared to revisit

the topic throughout the course of treatment.

This should be done in an empathic and nonjudgmental manner, emphasizing the clinician’s

concern for the client’s general health and wellbeing. Initial interventions should be tailored

to the client’s stage of change (Prochaska et al.

1992), with a focus in the earlier stages on providing information, exploring ambivalence,

eliciting client concerns, and beginning to envision the possibility of quitting.

For people who smoke who are not yet ready to

quit, the clinician can do effective motivational

interventions that will keep the client thinking

about quitting at some time in the future.

Discussing reasons for the person to consider

quitting—for example, carbon monoxide (CO)

monitor readings, costs, short­ and long­term

health consequences of smoking, benefits of

quitting specific to the individual, and the factors that may have prevented an attempt—is

important. Written materials about tobacco

dependence and treatment options with brief

advice to quit is one method of providing such

information and increasing motivation.

Another is to follow the “5 Rs” as outlined in

the Surgeon General’s guidelines (U.S. Public

Health Service, Office of the Surgeon General

2004):

• Relevance: Encourage the client to indicate

why quitting could be personally relevant,

being as specific as possible.

• Risks: Motivational information has the

greatest impact if it is relevant to a client’s

disease status or risk, family or social situation (e.g., having children in the home),

health concerns, age, gender, and other

important client characteristics (e.g., prior

quitting experience, personal barriers to cessation).

• Rewards: Elicit from clients possible benefits

of quitting, with a particular focus on identifying short­term benefits that they will notice

immediately.

• Roadblocks: Help the client to identify barriers or impediments to quitting. Typical barriers might include withdrawal symptoms, fear

of failure, weight gain, lack of support,

depression, or enjoyment of tobacco.

• Repetition: The motivational intervention

should be repeated every time an unmotivated client visits the clinical setting. People who

use tobacco and who have failed in previous

quit attempts should be informed that most

people make repeated quit attempts before

they are successful.

Preparation for quitting may include self­monitoring or keeping a diary of smoking, planning

rewards for successful abstinence, seeking

additional information about treatment, purchasing the medication to aid in quitting,

attempting to not smoke in certain situations or

locations (such as the car, in the house) to

enhance perceived self­control over smoking,

and making a list of reasons for and potential

benefits of quitting. Sources of social support

should also be identified.

Screening and assessment

All clients should be screened for tobacco use

beginning with an assessment of current and

Specific Mental Disorders: Additional Guidance for the Counselor 339
past patterns of tobacco use (number of

cigarettes smoked per day, times during the

day, location, and circumstances). For individuals who currently smoke, a more comprehensive assessment should be completed (see text

box below).

In addition to self­reported amount of tobacco

use, the amount of tobacco usage can be

assessed more objectively through cotinine or

CO levels. Cotinine levels can be obtained from

the urine, blood, or saliva to assess the amount

of nicotine ingested. Cotinine is a primary

metabolite of nicotine and remains in the body

for several weeks. The expired­air test for a CO

level is inexpensive and can be obtained within

a minute by any clinician with a CO meter. The

CO meter is useful at intake and to monitor for

relapse. Higher cotinine and CO levels are

associated with a higher number of cigarettes

per day and also severity of nicotine withdrawal. Despite the usefulness of these biochemical

measures, they are frequently unavailable in

clinical settings.

Assessment of tobacco withdrawal symptoms in

the past and during the early abstinence period

can be helpful. Clients can be educated that

these symptoms will reduce substantially after

2 weeks (see Figure D­2).

The severity of nicotine dependence can be

assessed with the Fagerstrom Test for Nicotine

Dependence (FTND) (see Figure D­3, p. 342), a

six­item, self­report measure that has been

shown to predict withdrawal symptom and

craving severity (Payne et al. 1994). Two questions from the FTND that assess the number of

cigarettes per day and time elapsed before the

first cigarette have been shown to perform

about as well as the full scale (Hajek et al.

2001; Kozlowski et al. 2004). As a clinical

guideline, those who smoke at least 10

cigarettes per day have moderate nicotine

dependence, while those who smoke more than

20 cigarettes per day have high nicotine dependence. Similarly, those who smoke within 60

minutes of waking can be considered to have

moderate dependence, and those who smoke

within 30 minutes of waking can be considered

to have high dependence. Because of the

unique social circumstances of people with

schizophrenia, the FTND may not be an ideal

measure of nicotine dependence for this popuAssessing Nicotine Use and Nicotine Dependence

Source: Ziedonis and Fiester 2003.

Current and past patterns of tobacco use (include multiple sources of nicotine)

Severity of tobacco dependence (e.g., Fagerstrom Scale)

Current motivation to quit

Breath CO level or cotinine level (saliva, blood, urine)

Assess prior quit attempts (number of attempts and what happened in the more recent attempts), why

the client quit, how long the client was abstinent, why the client relapsed, what treatment did the client

use (how was it used and for how long)

Assess withdrawal symptoms

Psychiatric and substance use histories

Medical conditions

Common triggers (car, people, moods, home, phone calls, meals, etc.)

Perceived barriers against quitting and supports for treatment success

Preference for treatment strategy

340 Specific Mental Disorders: Additional Guidance for the Counselor
lation. For example, items intended to assess

the need to smoke in response to overnight

abstinence may elicit artificially low scores

among people who smoke who are not permitted to smoke first thing in the morning by

group home staff, day treatment staff, or family members with whom they live (Steinberg et

al. 2004a).

Assessment of a client’s prior tobacco treatment

and cessation attempts should include the

nature of the prior treatments, length of abstinence, timing of relapse, and factors specifically

related to relapse (e.g., environmental or interpersonal triggers). Assessing prior treatments

includes assessing medications and psychosocial

treatments. Important information about medications includes asking about the dose level of

medications and for how long they were taken;

any side effects that developed; and how the

client actually took the medication.

Psychosocial treatments might include group or

individual treatment, American Lung

Association and other community support

groups, hypnosis, acupuncture, or attendance

at Nicotine Anonymous meetings. A history of

specific withdrawal symptoms and their severity

and duration is critical, as is an assessment of

Figure D­2

DSM­IV Criteria for Nicotine Withdrawal

Source: APA 2000, p. 266. Reprinted with permission.

A. Daily use of nicotine for at least several weeks.

B. Abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours

by four (or more) of the following:

(1) dysphoric or depressed mood

(2) insomnia

(3) irritability, frustration, or anger

(4) anxiety

(5) difficulty concentrating

(6) restlessness

(7) decreased heart rate

(8) increased appetite or weight gain

C. The symptoms in criterion B cause clinically significant distress or impairment in social, occupational,

or other important areas of functioning.
 

The symptoms are not due to a general medical condition and are not better accounted for by another
 

mental disorder.
 

Associated features:

• Craving for nicotine

• Desire for sweets

• Impaired performance on tasks requiring vigilance

• EEG slowing

• Decrease in catecholamine and cortisol levels

• Decreased metabolism of medications and other substances

Specific Mental Disorders: Additional Guidance for the Counselor 341
the person’s social and environmental contexts;

for example, whether other household members

smoke and the availability of family and social

supports (Ziedonis and Fiester 2003).

An assessment should be made of the person’s

reasons for quitting and his or her motivation,

commitment, and self­efficacy (perceived ability to quit). The individual’s stage of readiness

for stopping smoking is also important; that is,

whether the person is not yet seriously considering stopping smoking (precontemplation), is

considering attempting to quit but not for several months (contemplation), is seriously considering quitting in the next month and has

begun to think about the necessary steps to

stop smoking (preparation), or is actually

attempting to stop smoking (action).

Patient motivation: Although 70 percent of

people who smoke express an interest in quitting, only 8 percent are planning to make a

quit attempt in the next month (Wewers et al.

2003). Stages of change can be assessed using

the following simple algorithm:

• Client is not planning to quit in the next 6

months (precontemplation)

• Client is planning to quit in the next 6

months, but not the next month (contemplation)

• Client is planning to quit in the next month

(preparation)

Client self­efficacy: Clients with little confidence in their ability to quit are less likely to

make a quit attempt and less likely to succeed if

they do.

Figure D­3

The Fagerstrom Test For Nicotine Dependence

Scores are totaled to yield a single value, with scores of 6 or more indicating high nicotine dependence.

Question Answer Score

How soon after you wake up do you smoke your first

cigarette?

Within 5 minutes

6–30 minutes

31–60 minutes

> 60 minutes

3

2

1

0

Do you find it difficult to refrain from smoking in places

where it is forbidden?

Yes

No

1

0

Which cigarette would you hate to give up the most? The first one in the

morning

Others

1

0

How many cigarettes per day do you smoke? < 10

11–20

21–30

> 31

0

1

2

3

Do you smoke more frequently during the first hours after

waking than during the rest of the day?

Yes

No

1

0

Do you smoke if you are so ill that you are in bed most of

the day?

Yes

No

1

0

342 Specific Mental Disorders: Additional Guidance for the Counselor
Environmental factors and social support:

People who smoke find it harder to quit when

they live and work alongside other people who

smoke, have a high current stress level, or have

a history of mental disorders. This is particularly true in mental disorder treatment settings

or communal living arrangements where clients

are commonly exposed to staff and other clients

who smoke.

Client beliefs about smoking and quitting: For

example, older adults who smoke may believe

that they are less likely to be able to quit, or

that they will experience few health benefits if

they do so. In fact, most studies find the opposite—that older adults who smoke, (i.e., who

have smoked the longest) have a higher probability of success on any given quit attempt

(Stapleton et al. 1995). Similarly, some clients

and clinicians believe that nicotine causes cancer and that NRTs are dangerous. This is clearly not the case, and addressing this common

misconception can help to increase motivation

to quit.

Interventions

The U.S. Public Health Service Clinical

Practice Guideline on Treating Tobacco Use

and Dependence (Fiore et al. 2000a) advises

clinicians to use the “5 A’s” (Ask, Advise,

Assess, Assist, Arrange Followup) with every

person who uses tobacco who shows a willingness to quit (see chapter 8 for more information). The 5 A’s are a brief and simple tobacco

intervention that has been shown to increase

the quit rates in primary care settings (Katz et

al. 2002). Unfortunately, they are rarely implemented by clinicians treating clients in behavioral healthcare settings. This may be because

clinicians are unsure how to implement them in

daily practice, or because the guideline gives

little information on the assessment of tobacco

use in these complex clients.

Treatment Planning

All clients who smoke should have tobacco

dependence as a problem listed in their treatment plans and motivation­based treatment

plans written to match their motivation to

address tobacco. Those with less motivation

can receive written information and motivational interventions. For clients interested in

tobacco dependence treatment a “quit date”

should be selected. After cessation, close monitoring should occur during the early period of

abstinence. Before the quit date, the person

should be encouraged to explore and organize

social support for the self­attempt. Plans to

minimize cues associated with smoking (e.g.,

avoiding circumstances likely to contribute to

relapse) are important, as is considering alternative coping behaviors for situations with a

higher potential for relapse. A telephone or

face­to­face followup during the first few days

after cessation is critical because this is the time

that withdrawal symptoms are most severe,

and 65 percent of patients relapse within 1

week. A followup face­to­face meeting within 1

to 2 weeks allows a discussion of problems that

have occurred (e.g., difficulties managing craving) and serves as an opportunity to provide

reinforcement for ongoing abstinence. Even

after the early period of abstinence, periodic

telephone or face­to­face contacts can provide

continued encouragement to maintain abstinence, allow problems with maintaining abstinence to be addressed, and provide feedback

regarding the health benefits of abstinence.

Figure D­4, p. 344, provides several strategies

for counselors to use in helping clients stop

smoking.

How To Treat Tobacco

Dependence

Before making a quit attempt, clients should

know the psychopharmacological options (i.e.,

NRT and bupropion) and what to expect while

trying to quit. This knowledge may inoculate

people who smoke from the frustration they

might otherwise experience with the discomfort

of quitting. Clients should know about the

withdrawal symptoms they may experience, the

fact that many people quit several times before

quitting successfully, and the potential for

minor weight gain. Clinicians should also discuss the timing of the quit attempt to maximize

Specific Mental Disorders: Additional Guidance for the Counselor 343
Figure D­4

Brief Strategies for Smoking Cessation

Source Fiore et al. 2000a, b.

Action Strategies for Implementation

Help the client with a quit

plan.

A client’s preparations for quitting

•

•

•

•

Set a quit date—ideally, the quit date should be within 2 weeks.

Tell family, friends, and coworkers about quitting and request understanding

and support.

Anticipate challenges to planned quit attempt, particularly during the critical

first few weeks. These include nicotine withdrawal symptoms.

Remove tobacco products from your environment. Prior to quitting, avoid

smoking in places where you spend a lot of time (e.g., work, home, car).

Provide practical counseling (problem solving/skills

training).

Abstinence—Total abstinence is essential. “Not even a single puff after the quit

date.”

Past quit experience—Identify what helped and what hurt in previous quit

attempts.

Anticipate triggers or challenges in upcoming attempt—Discuss challenges/triggers and how client will successfully overcome them.

Alcohol—Since alcohol can cause relapse, the client should consider abstaining

from alcohol while quitting.

Other smokers in the household—Quitting is more difficult when there is another smoker in the household. Clients should encourage housemates to quit with

them or not smoke in their presence.

Provide intra­treatment

social support.

Provide a supportive clinical environment while encouraging the client in his or

her quit attempt. “My office staff and I are available to assist you.”

Help client obtain extratreatment social support.

Help client develop social support for his or her quit attempt in his or her environments outside of treatment. Have the client ask his or her spouse/partner,

friends, and coworkers to support the client in the quit attempt.

Recommend the use of Recommend the use of pharmacotherapies found to be effective in this guideapproved pharmacothera­ line. Explain how these medications increase smoking cessation success and

py, except in special cir­ reduce withdrawal symptoms. The first­line pharmacotherapy medications

cumstances. include bupropion SR, nicotine gum, nicotine inhaler, nicotine nasal spray, and

nicotine patch.

Provide supplementary Sources—Federal agencies, nonprofit agencies, or local/State health

materials. departments.

Type—Culturally/racially/educationally/age appropriate for the client.

Location—Readily available at every clinician’s workstation.

344 Specific Mental Disorders: Additional Guidance for the Counselor
the chances for success. In contrast to other

drugs of abuse, it is recommended that people

who smoke take 2 to 4 weeks to prepare for the

quit date. Clients with few mental health problems may be ready in 2 weeks, while people with

more serious mental illnesses should take longer

to prepare. Once a quit date is set, a decision

must be made regarding making an abrupt or

gradual change. Making a gradual change has

the disadvantage of making each cigarette more

enjoyable as the number of cigarettes decreases,

with the result that the last few cigarettes may

be very difficult to give up.

Other preparatory strategies include using

“behavioral disconnects,” publicizing the

planned quit attempt, and creating a detailed

coping plan for dealing with cravings after the

quit date. Behavioral disconnects involve using

the preparation time to practice not smoking in

the client’s usual contexts. For example, if the

client is accustomed to smoking while speaking

on the telephone, he or she can practice speaking on the phone without smoking cigarettes.

This strategy has the dual benefit of increasing

self­efficacy if done successfully and of decreasing psychological cravings in the presence of

the client’s usual smoking cues.

By publicizing the planned quit attempt, the

client is likely to feel more committed to following through on the quit day. It is helpful to tell

as many significant others as possible, including all friends, family, coworkers, and so on.

Telling other treatment staff is also important,

as supportive treatment staff can play a key

role in encouraging the change. The client

should also be informed of the potential effects

of smoking on psychotropic medications, as

aromatic hydrocarbons (tar) in the tobacco

smoke increases the metabolism of many of the

medications the client may be taking. Upon

quitting smoking, the medications may need to

be adjusted accordingly.

Publicizing the planned quit attempt will also

help in gathering the social support needed to

be successful. Significant others who do not

smoke are likely to be supportive, and those

who do smoke can be put on notice that they

should not offer cigarettes or sabotage the quit

attempt. The detailed coping plan should

include having a reference sheet with several

individualized reasons for quitting, names and

phone numbers of supportive others to call,

and a list of distracting activities, preferably

those that are inconsistent with smoking (e.g.,

exercising, playing with children).

As the quit date approaches, stimulus control

techniques should be implemented, such as

removing all tobacco product cues (e.g.,

cigarettes, lighters, ashtrays) from the client’s

environment. The client should also make sure

others do not smoke in the home, be prepared

to sit in non­smoking areas, and avoid smoking

cues that can be avoided.

Avoiding smoking cues is often difficult for people who smoke and have other substance use or

mental disorders. Clients with other substance

use disorders may be faced with smoke­filled

12­Step program meetings, sponsors who

smoke, or even sponsors who discourage them

from quitting. Clients with mental disorders

may be faced with group home housemates who

smoke and day treatment programs populated

by people who smoke. It is helpful to have

other supportive treatment staff to intervene in

these circumstances to facilitate the quit

attempt. Regardless of the co­occurring disorder, it is important to take into account the

specific deficits or circumstances secondary to

the disorder.

An in­person or telephone followup contact

should occur within 2 days of the quit date.

Clinicians and clients should have an action

plan for managing a lapse or relapse, and this

plan should be activated if the client slips and

has a cigarette. After the client has quit,

relapse prevention strategies should be used.

Popularized by Marlatt and Gordon (1985),

relapse prevention is a well­established, empirically based approach using cognitive–behavioral therapy techniques to teach people to

avoid and/or cope with triggers to use addictive

substances. Since cravings or urges to use

addictive substances are common issues for

clients seeking treatment for substance use disSpecific Mental Disorders: Additional Guidance for the Counselor 345
orders (including nicotine dependence), clients

are taught how to manage and cope with these

feelings and avoid smoking cues whenever possible. Common cues for smoking include the

people, places, and things associated with

tobacco use as well as negative mood states like

anger or sadness. These cues can trigger smoking behavior and can be lessened through psychosocial interventions.

Medications for nicotine
 

dependence treatment
 

Six medications have received Food and Drug

Administration (FDA) approval for nicotine

dependence treatment, and the practice guidelines recognize these medications as first­line

treatments (Fiore et al. 2000a). These treatments are effective for about 25 to 30 percent

of people in the general population who smoke

on any one attempt, and this rate increases

with combined psychosocial treatment. These

medications have similar success rates but have

side effect differences.

The five types of NRTs are administered in a

variety of ways: nicotine polacrilex (gum), nicotine transdermal patch, nicotine inhaler, nicotine nasal spray, and the nicotine lozenge.

These medications are similar in how they

reduce nicotine

withdrawal and urge

to smoke, and

improve abstinence

rates and client satisfaction. The only

FDA­approved nonnicotine treatment is

bupropion SR (marketed as Zyban SR)

for tobacco addiction and Wellbutrin

SR for treatment of

depression.

Bupropion’s effect

on tobacco dependence, however, is

independent of

depression status.

Bupropion SR has proven effectiveness in

clients with or without past depression medication treatment.

Relapse	 

prevention uses

social skills training to teach drug

refusal skills.

Most people who smoke and who have mental

disorders smoke heavily. People who smoke

heavily usually have higher CO and cotinine

levels, higher Fagerstrom nicotine dependence

scores, more nicotine withdrawal symptoms,

and experience mood difficulties during withdrawal. There is some evidence to suggest

titrating the dosage of NRT to the cotinine levels in the client. People who smoke heavily may

have improved outcomes with higher NRT

dosages (multiple NRTs simultaneously, multiple NRT patches), adding bupropion SR, and

integrating behavioral therapies. There is one

report that high­dose patch treatment resulted

in 40 percent fewer withdrawal symptoms and

2.5 times greater reductions in craving in a

pilot study of people with schizophrenia who

smoked, and was well tolerated, although larger trials are needed.

Specific psychosocial 

treatments for tobacco

dependence

Psychosocial treatments for nicotine dependence are among the first­line treatments in

several practice guidelines (APA 1996; Fiore et

al. 2000a). Because behavioral health treatment

providers (i.e., those treating substance use

and/or mental disorders) possess many of the

skills needed to provide tobacco dependence

services, intensive interventions may be well

suited to a mental or substance use disorder

treatment setting. Data support the use of psychosocial interventions for tobacco dependence

as provided by various counselor disciplines

(e.g., physicians or nonphysicians), and via

multiple treatment modalities (e.g., telephone,

group, and individual counseling). Although

there is a clear dose­response relationship

between counseling intensity and success, even

very brief counseling can increase quit rates

(Fiore et al. 2000a).

346 Specific Mental Disorders: Additional Guidance for the Counselor
Despite the strong evidence that psychosocial

treatments are effective for treating tobacco

dependence, only 5 percent of people who smoke

who make a 24­hour quit attempt receive counseling as part of their treatment (Zhu et al.

2000). Clients who are motivated to quit smoking should be taught general problemsolving

skills, provided with social support as part of

counseling, and assisted in gaining social support

from family and friends for their quit attempt.

Psychosocial interventions have been successfully adapted for people with schizophrenia who

smoke (Addington et al. 1998; George et al.

2000; Steinberg et al. 2004a; Ziedonis and

George 1997), depression (Hall et al. 1994,

1995, 1996, 1998, 1999), and substance use disorders (e.g., Burling et al. 2001; Patten et al.

1998, 2001). Successful adaptation involves

blending traditional mental health services with

tobacco dependence treatments while addressing the unique problems associated with the specific mental disorder. Integrating medications

with these psychosocial treatments is also very

important, since these groups are often highly

dependent on tobacco.

While clinicians are often hesitant to help

clients with serious mental illness who smoke to

quit smoking, the Clinical Practice Guideline

(Fiore et al. 2000a) recommends that tobacco

use be addressed in all clients who smoke.

While many excuse smoking in this population,

it should be recognized that smoking exacerbates many existing problems. When compared

with people who do not smoke, those with

schizophrenia who smoke exhibited more positive symptoms of schizophrenia (Goff et al.

1992; Ziedonis et al. 1994) and experienced

more hospitalizations than their counterparts

who did not smoke (Goff et al. 1992; Kelly and

McCreadie 1999). People with schizophrenia

who smoke often are prescribed more antipsychotic medication than people with schizophrenia who do not smoke, due to an increased

metabolism of many psychiatric medications

secondary to the “tar” or aromatic polynuclear

hydrocarbons—not due to nicotine (Goff 1992;

Hughes 1993; Ziedonis 1994). They also experience greater medication side effects such as

tremor (Kelly and McCreadie 1999), rigidity

(Ziedonis et al. 1994), and possibly tardive

dyskinesia (Nilsson et al. 1997). Tobacco use

also depletes their already scarce financial

resources. Cigarettes may constitute up to 27

percent of the monthly budget for people with

schizophrenia who smoke (Steinberg et al.

2004a). A recent study indicated that a brief

motivational interviewing intervention was

effective in motivating people with schizophrenia who smoked to seek formal tobacco dependence treatment (Steinberg et al. 2004b).

Relapse prevention also uses social skills training to teach drug refusal skills. Since seeing

others smoke is a strong predictor for relapse,

this approach is very important for those living

in a group home or attending a substance abuse

treatment or mental health services setting

where smoking may be ubiquitous. Specialized

treatments for this group should incorporate

techniques for reducing the appeal of smoke

breaks and learning to avoid “bumming”

cigarettes or accepting an offered cigarette.

Interactive teaching through role playing can

enhance this type of learning and allow for

real­world practicing. Raising awareness of the

stigma related to these drug­seeking and druguse behaviors can also help to change behavior.

Creating a relapse analysis is helpful to understand the role of “seemingly irrelevant decisions” in the path toward a relapse. An example of a “seemingly irrelevant decision” might

be a relapse to smoking after dining in the

smoking section of a restaurant rather than sitting in the nonsmoking section.

Relapse prevention also distinguishes between

a “lapse” and a “relapse” as a matter of degree

and severity. There is a focus on trying to

avoid letting a “lapse” become a “relapse” by

quickly managing the situation and framing it

as a learning opportunity in an effort to return

to abstinence. This model allows for some mistakes as the client is working toward a goal of

abstinence. Figure D­5 (p. 348) presents

strategies for helping clients address situations

that may lead to relapse.

Specific Mental Disorders: Additional Guidance for the Counselor 347
Figure D­5

Brief Strategies 2. Components of Prescriptive Relapse Prevention

Source: Fiore et al. 2000a, b.

During prescriptive relapse prevention, a client might identify a problem that threatens his or her abstinence.

Specific problems likely to be reported by clients and potential responses follow:

Problems Responses

Lack of support for cessation

Negative mood or depression

•

•

•

•

•

Schedule followup visits or telephone calls with the client.

Help the client identify sources of support within his or her environment.

Refer the client to an appropriate organization that offers cessation counseling or support.

If significant, provide counseling, prescribe appropriate medications, or refer

the client to a specialist.

If the client reports prolonged craving or other withdrawal symptoms, consider extending the use of an approved pharmacotherapy or adding/combining

pharmacological medications to reduce strong withdrawal symptoms.

Strong or prolonged withdrawal symptoms

• If the client reports prolonged craving or other withdrawal symptoms, consider extending the use of an approved pharmacotherapy or adding/combining

pharmacological medications to reduce strong withdrawal symptoms.

Weight gain •

•

•

•

•

Recommend starting or increasing physical activity; discourage strict dieting.

Reassure the client that some weight gain after quitting is common and

appears to be self­limiting.

Emphasize the importance of a healthy diet.

Maintain the client on pharmacotherapy known to delay weight gain (e.g.,

bupropion SR and NRTs, particularly nicotine gum).

Refer the client to a specialist or program.

Flagging motivation/feeling

deprived

•

•

•

•

Reassure the client that these feelings are common.

Recommend rewarding activities.

Probe to ensure that the client is not engaged in periodic tobacco use.

Emphasize that beginning to smoke (even a puff) will increase urges and make

quitting more difficult.

Personality Disorders

(Overview)

Description

Personality disorders (PD) are rigid, inflexible,

and maladaptive behavior patterns of sufficient

severity to cause significant impairment in

functioning or internal distress. Personality

disorders are enduring and persistent styles of

behavior and thought, rather than rare or

unusual events in someone’s life. Furthermore,

as opposed to a response to a particular set of

circumstances or particular stressors, people

with personality disorders carry with them

these destructive patterns of thinking, feeling,

348 Specific Mental Disorders: Additional Guidance for the Counselor
and behaving as their way of being and interacting with the world and others.

Though sudden stressful circumstances might

worsen the response of a client with a PD, such

a client experiences the disorder regularly and

often pervasively. Clients with PDs frequently

are unaware of the impact of the disorder on

their personality, behaviors, and interactions

with others. Sometimes clients with PDs blame

others or the world for misery that they clearly

bring upon themselves.

The course and severity of PDs can be worsened by the presence of other mental disorders

such as mood, anxiety, and psychotic disorders. Furthermore, of the roughly 10 different

types of PDs that can be described, people with

any one of the disorders are at an increased

likelihood of having another—that is, though

the different PDs can be discussed as if they

were separate entities, in clinical practice,

clients often have more than one PD and might

well have features of many.

“Mixed personality disorder,” the mental

health equivalent of “polysubstance abuse,”

describes individuals who meet the diagnostic

criteria for more than one PD. This TIP provides details about two of the PDs—borderline

personality disorders (BPDs) and antisocial

personality disorders (APDs). Before exploring

BPD and APD in detail, a brief overview of the

other PDs follows. However, the reader should

keep in mind that the diagnostic approach to

personality disorders is slated for significant

change and refinement, as there have been

numerous concerns expressed about the meaningfulness and utility of the current system for

diagnosing personality disorders (see footnote1

for more information).

Personality disorders grouped

into clusters A, B, or C

The PDs include paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, and obsessive­compulsive. In the DSM­IV­TR (pp. 690–730), PDs

are conceptualized as three distinct clusters,

“A,” “B,” and “C:”

• Cluster A: Paranoid PD; Schizoid PD; and

Schizotypal PD

• Cluster B: Antisocial PD; Borderline PD;

Histrionic PD; and Narcissistic PD

• Cluster C: Avoidant PD; Dependent PD; and

Obsessive­Compulsive PD

Cluster A

Cluster A PDs describe clients who may be seen

as “odd­eccentric.”

People with paranoid personality disorder are

pervasively distrustful and suspicious to a

degree that routinely interferes with their forming a correct perception of the motives and

beliefs of others, and with their successfully

forming positive relationships with others.

They may interpret other people as trying to

threaten, demean, or intimidate them, even

when such behavior is not exhibited.

Schizoid personality disorder is descriptive of a

person whom others often see as a “loner” and

who commonly exhibits an indifference to the

views and feelings of others. People with a

schizoid personality disorder have a restricted

range of emotional experience and expression.

People with a schizotypal personality disorder

often behave in ways others see as weird, with

possible peculiarities of speech, dress, and/or

1

A group of clinicians committed to a research agenda for the development of DSM­V have given the following assessment of the status of personality disorders within the DSM­IV­TR (APA 2000): “... there is notable dissatisfaction with

the current conceptualization and definition of the DSM­IV­TR (APA 2000). Problems identified by both researchers

and clinicians include confusion regarding the relationship between the DSM­IV­TR personality disorders (especially

those that are chronic and have their onset in childhood or adolescence); excessive comorbidity among the DSM­IV­TR

personality disorder; arbitrary distinction between normal personality, personality traits, and personality disorders;

and limited coverage (the most common diagnosed personality disorder is the residual diagnosis of personality disorder

not otherwise specified)” (First et al. 2002).

Specific Mental Disorders: Additional Guidance for the Counselor 349
beliefs. These strange or markedly unusual

characteristics often produce avoidance or

wariness in others, and the resulting difficulties

in interpersonal relations may lead to anxieties

and depression.

Cluster B

Cluster B PDs include histrionic PDs and narcissistic PDs, in addition to the borderline and

antisocial PDs (which are discussed in detail in

following sections). The general characterization of the Cluster B dimensions is “dramaticemotional.”

Histrionic personality disorder is expressed in

excessive emotionality and attention seeking,

often including inappropriate sexually seductive behaviors.

Clients with narcissistic personality disorder

exhibit a “pervasive pattern of grandiosity,

need for admiration, and lack of empathy”

(APA 2000, p. 714). While a certain self­centeredness and falsity are common with addictive disease, a client with a true narcissistic disorder displays a grandiosity, over­inflates the

value of his or her own abilities, and displays a

superiority that is so distorted as to impair his

or her judgment. People with narcissistic PD

and substance use disorders will exhibit these

features even after achieving and maintaining

abstinence.

Antisocial personality disorder involves a history of chronic antisocial behavior that begins

before the age of 15 and continues into adulthood (though the diagnosis cannot be made

officially unless a person is at least 18 years

old). The disorder is manifested by a pattern of

irresponsible and antisocial behavior indicated

by illegal activities, recklessness, impulsive

behavior, academic failure, and poor job performance. Other features often include dysphoria, an inability to tolerate boredom, feeling victimized, and a diminished capacity for intimacy.

Borderline personality disorder is characterized by unstable mood and self­image, and

unstable and intense interpersonal relationships. These people often display extremes of

overidealization and devaluation, marked

shifts from baseline to an extreme mood or

anxiety state, and impulsiveness.

Though people with APD are more likely to be

male and those with BPD female, APD and

Figure D­6

Characteristics of People With Antisocial and Borderline Personality Disorders

Characteristic Antisocial Borderline

Affect Angry intimidation Angry self­harm

World view If you don’t do what I want, you’ll be

sorry.

I deserve it all.

They’re the ones with the problem.

I’ve got to get you before you get me.

I don’t deserve to exist.

Help me, help me, but you can’t.

Presenting problem Legal difficulties, polysubstance abuse and

dependence, parasitic relationships

Self­harm, impulsive behavior, episodic

polysubstance abuse, hot­and­cold relationships

Social functioning Episodic achievement Gross dysfunctioning

Motivation Self­esteem Safety

Defenses Rationalization, projection Splitting, projection

350 Specific Mental Disorders: Additional Guidance for the Counselor
BPD have a number of features in common.

Both disorders tend to diminish in intensity

with age, and sometimes even remit after a

client reaches age 40 or so. People with APD

or BPD are likely to show features of other

PDs. Both APD and BPD are commonly associated with a co­occurring substance use disorder as well as with other significant (Axis I)

mental health complaints. Characteristics of

people with APD and BPD are presented in

Figure D­6.

Cluster C

Cluster C PDs include avoidant PD, dependent

PD, and obsessive­compulsive PD and describe

clients who are “anxious­fearful.”

People with avoidant personality disorder show

extreme hypersensitivity to others, social discomfort, and timidity, often with accompanying

depression, anxiety, and anger for failing to

develop social relations.

People with obsessive­compulsive personality

disorder display a preoccupation with orderliness, perfectionism, and control, and they may

appear excessively conscientious, moralistic,

scrupulous, and judgmental. Symptoms may

include distress associated with indecisiveness

and difficulty in expressing tender feelings,

feelings of depression, and anger about feeling

controlled by others.

Clients with dependent personality disorder

live with a pervasive and excessive need to have

others take care of them. Individuals with a

dependent PD typically have severely low selfesteem, and their behavior often is submissive

and clinging. Such individuals are at risk of

forming abusive relationship and even of failing

to protect their children from abuse.

Differential Diagnosis

The clinical situation often is challenging when

working with clients who have both a PD and a

substance use disorder. PDs should not be

diagnosed during substance use or withdrawal

as misdiagnosis can easily occur if the current

and historical roles of substance use are not

properly assessed. A period of abstinence is

often required before the co­occurrence of a

PD with a substance use disorder can be determined. If a PD coexists with substance use, the

PD will remain during abstinence. When a

bona fide co­occurring PD exists, during abstinence and recovery the PD symptoms can get

worse and the functioning level of the client

might even deteriorate, though over time

improvement and greater stability are possible

for the client with co­occurring personality disorder and substance use disorder who receives

effective care for both.

Some criteria that describe PDs (e.g., dependency or insensitivity) are also characteristic of

other Axis I disorders. Three PDs—paranoid,

schizoid, and schizotypal—may be distinguished from psychotic disorders by being

observed when the client is clearly not experiencing a psychotic episode (APA 2000).

Counselors are cautioned to take into account

the individual’s ethnic, cultural, and social

background when judgments are made about

personality functions. To make a sound judgment when working with a client who has an

unfamiliar cultural background, it is a good

idea to consult with someone who is familiar

with that culture to gain a sense of norms and

alternative, culturally consonant explanations

of observed behaviors.

Prevalence

Nace (1990) contends that the prevalence of

PDs is at least 50 percent in substance­abusing

populations. Brooner et al. (1997) found that

35 percent of the 716 consecutive admissions to

a methadone maintenance program had a personality disorder, while Flynn et al. (1996) in

the large Drug Abuse Treatment Outcome

Study of over 7,400 clients with substance

dependence found antisocial personality disorder in 34.7 percent for alcohol­only clients, 27

percent for heroin only, 30.4 percent for

cocaine only, percentages in the mid­40 percent

range for clients dependent on two of these

three drugs, and 59.8 percent for clients

dependent on all three drugs. As noted, howevSpecific Mental Disorders: Additional Guidance for the Counselor 351
er, no diagnosis should be made during the

acute phase of detoxification. The early phases

of treatment involve addressing behaviors that

may appear to be symptoms of PDs, especially

BPD. Thus, counselors should exercise care

not to rush to conclude that a patient or client

has BPD.

Among Cluster A disorders (“odd­eccentric”),

paranoid PD has been reported to be 0.5 to 2.5

percent in the general population, as high as 10

to 30 percent among those in inpatient mental

health settings, and 2 to 10 percent among

those in outpatient mental health clinics (APA

2000). One study found 44 percent of persons

in treatment for alcoholism to have this disorder (Dowson and Grounds 1995). Another

study (Verheul et al. 2000) found through semistructured interviews that 13.2 percent of a

group of 370 patients in treatment for substance abuse warranted a diagnosis of a paranoid personality disorder. Schizoid PD is

believed to be uncommon in clinical settings

(APA 2000). Similarly, although up to 3 percent of the general population may be affected

by schizotypal PD (APA 2000, p. 699), the

prevalence rate even in substance abuse treatment programs that treat clients with COD

appears to be quite low.

Among Cluster B disorders (“dramatic/emotional”), about 1 percent of females and 3 percent of males in the general population are

believed to have antisocial PD. In clinical settings, the prevalence is estimated to be anywhere from 3 percent to as high as 30 percent,

with especially high prevalence in substance

abuse treatment and prison settings (APA

2000). Among the male prison population, 20

percent or more may have antisocial PD.

Borderline PD also is relatively common in

mental health settings. Although only about 2

percent of the general population has this disorder, its incidence is about 10 percent of mental health clinic outpatients and 20 percent of

mental health inpatients. From 30 to 60 percent of other clinical populations may have this

disorder. One study of 370 clients in substance

abuse treatment (Verheul et al. 2000) found

that more had Cluster B diagnoses (27 percent

antisocial PD and 18.4 percent borderline PD)

than either Cluster A (13.2 percent) and

Cluster C (18.4 percent avoidant).

The DSM­IV suggests prevalence rates of 2 to 3

percent for histrionic PD in the general population and 10 to 15 percent in mental health

settings; there is reason to believe the 10 to 15

percent estimate would also be true of substance abuse treatment settings (APA 2000).

Prevalence rates for narcissistic PD are estimated to be roughly similar to those for histrionic PD—from 2 to 16 percent in the clinical

population (APA 2000) and about 10 to 15 percent in the clinical practice of a substance

abuse counselor.

Among Cluster C disorders (“anxious/fearful”),

avoidant PD and obsessive­compulsive PD

probably each make up at most 10 percent of

clients at mental health clinics. With a rate in

the general population of less than 1 percent for

each, substance abuse counselors seldom see

pure forms of these types of PDs in clinical practice. On the other hand, persons with dependent

PD are “among the most frequently... encountered in mental health clinics” (APA 1994).

Again, the reader is cautioned that the utility

and meaningfulness of the Cluster groupings

and/or the distinctiveness of the 10 separate

“personality disorders” is in doubt. Bohn and

Meyer (1999) report that frequencies of antisocial PD “in samples of alcoholic patients have

ranged from 16 to 49 percent. Somewhat higher

rates have been detected among opioid­ and

other drug­abusing populations. The frequency

of occurrence of ASPD [antisocial PD] varies

depending on the type of sample and the diagnostic criteria used [emphasis added]

(Hesselbrock et al. 1985; Rounsaville et al.

1983). The higher reported prevalence rates of

ASPD among substance­dependent patients

since 1980 ... are likely a function of the broad

diagnostic criteria applied to this disorder by

DSM­III, DMS­III­R, and DSM­IV, rather than

of a real change in the patient population”

(Bohn and Meyer 1999, p. 99). In fact, North

and colleagues found that antisocial PD

appeared to change little over 20 years within

352 Specific Mental Disorders: Additional Guidance for the Counselor
the homeless population, with 10 to 20 percent

of homeless women and 20 to 25 of homeless

men receiving diagnoses of antisocial PD (see

North et al. 2004).

Substance Use Among People

With Personality Disorders

Substance use may trigger or worsen personality disordered behaviors. No single pattern of

substance use or abuse can be identified for

any one PD; the drug or drugs of abuse depend

on many factors beyond the presence of a specific PD. For example, individuals with paranoid PD may prefer stimulants to augment

their need to be vigilant or they may seek opioids to reduce the severe tension generated by

their fear and distrust.

Plans to place the diagnosis of PDs on a solid

research foundation (including the ever­growing body of neurobiological knowledge) that

will yield diagnoses useful for clinical practice

(Kupfer et al. 2002) envision significant

changes to the DSM­IV­TR presentation of

PDs. In brief, it seems that a more complex

and psychometrically based set of categories

and measurement dimensions will be utilized

instead of 3 clusters and 10 PDs. The meaningful and useful relationships among the behaviors and treatment considerations relevant for

people with personality disorders may well

match up with categories and dimensions that

are not clearly enough represented by the current schema to yield treatment decisionmaking

information. Perhaps the future understanding

of people with personality disorders and DSMV will be useful to enhance the treatment

responses of these individuals, as the one thing

that is already clear from the available

research is that these individuals can change

and profit from treatment.

Key Issues and Concerns

Clients with PDs tend to have difficulty forming a genuinely positive therapeutic alliance.

They tend to frame reality in terms of their

own needs and perceptions and to be unable to

understand the perspectives of others.

Also, most clients with

PDs are limited in

terms of their ability

to receive, accept, or

benefit from corrective feedback. A further difficulty is the

strong countertransference clinicians can

have in working with

these clients, who are

adept at “pulling others’ chains” in a variety of ways. Specific

concerns will, however, vary according to

the PD and other

individual circumstances. In general, group

therapies, therapeutic communities, and more

rationally oriented, directive, behavioral forms

of treatment have been thought to be particularly appropriate for people with PDs.

Substance use

may trigger

or worsen personality disordered

behaviors.

Borderline Personality

Disorder

Description

One of the most prominent features of people

with BPD is instability. Their relationships

with others are likely to be unstable, with

reports of how wonderful an individual is one

day and expressions of intense anger, disapproval, condemnation, and even hate toward

that same individual a week later. Then a

month later the person with BPD is once again

singing the praises of the same person. These

reactions can be unsettling for a counselor,

especially if it is the counselor who is being held

in high esteem one minute and accused of every

form of deceit the next. The severe instability

experienced by the person with BPD includes

fluctuating views and feelings about him­ or

herself. Those with BPD often feel quite good

about themselves and their progress and optimistic about their future for a few days or

Specific Mental Disorders: Additional Guidance for the Counselor 353
weeks, only to have a seemingly minor experience turn their world upside­down with concomitant plunging self­esteem and depressing

hopelessness.

Basic instability extends to work and school,

where it sometimes seems that people with BPD

“snatch failure out of the jaws of success.”

Individuals with BPD might well be engaging

and attempt to please initially, then become

demanding, hostile, and exhausting. When

experiencing emotional states they cannot handle, clients with BPD can be at risk of suicidal,

self­mutilating, and/or brief psychotic states.

Since people with BPD typically seek mental

health or substance abuse treatment based on

their current life conditions and emotional

state, it is likely that the person with BPD who

seeks mental health treatment is acutely emotionally distraught, needing some relief from

how she or he feels. Similarly, the client with

BPD who chooses (or is directed to choose) a

substance abuse treatment program probably

is experiencing the substance use disorder as

the immediate target for treatment.

Consequently, the average admission of a person with BPD to a mental health environment

might, in general, be considerably different

from the average admission of a person with

BPD to a substance abuse treatment setting.

Evidence is accumulating that BPD, posttraumatic stress disorder (PTSD), and a history of

childhood abuse occur with regularity among

women in substance abuse treatment (Gil­Rivas

et al. 1996; Sullivan and Evans 1994). Women

with BPD are more likely to have eating disorders or PTSD, while men are more likely to

have co­occurring substance use disorders,

along with PTSD and other personality disorders (Johnson et al. 2003).

Substance Use Among People

With BPD

Individuals with BPD are often skilled in seeking multiple sources of medication that they

favor, such as benzodiazepines. Once this medication has been prescribed in a mental health

system, they may demand that it be continued.

Confrontation or pressure to engage in detoxification or outpatient withdrawal can precipitate

intense rage and various levels of client crises.

Individuals with BPD may well associate drugs

with social interaction and use the same drugs

of choice, route of administration, and frequency as the individuals with whom they are

interacting. On the other hand, they often use

substances in chaotic and unpredictable patterns. Polydrug use is common and may

involve alcohol and other sedative­hypnotics

taken for self­medication.

People with BPD usually have big appetites;

they experience powerful, emotion­driven

needs for something outside of themselves. If

they do give up alcohol and other drugs, perhaps because they are experiencing a positive

relationship to a service provider or a group,

they are extraordinarily vulnerable to meeting

their needs through other compulsive behaviors. Newly abstinent individuals with BPD

must be monitored for compulsive sexual

behavior, compulsive gambling, compulsive

spending/shopping, or other out­of­control

behaviors that result in negative or even dangerous consequences.

At the beginning of a crisis episode, a client

with BPD might take a drink or a different

drug in an attempt to quell the growing sense

of tension or loss of control. What the client

needs to learn is twofold: (1) that a drink/

drug at that point increases the harm and

real loss of control, and (2) that at the point

where a drug/drink is desired some other,

positive coping strategy needs to be put into

play immediately.

Key Issues and Concerns

Progress with clients who have BPD can be

slow. Therapists should be realistic in their

expectations and know that clients will try to

test them. To respond to such tests, therapists

should maintain a matter­of­fact, businesslike

attitude, and remember that people with PDs

often display maladaptive behaviors that have

354 Specific Mental Disorders: Additional Guidance for the Counselor
helped them to survive in difficult situations,

sometimes called “survivor behaviors.” (See

TIP 36, Substance Abuse Treatment for

Persons With Child Abuse and Neglect Issues

[Center for Substance Abuse Treatment

(CSAT) 2000d].)

It is important to educate clients about their

substance use and mental disorders. Clients

should learn that treatment for and recovery

from their substance use disorder may progress

at a different rate than their treatment for and

recovery from BPD. In addition, while many

clients appear to fully recover from their substance use disorders, the degree of long­term

recovery from BPD is less understood and

characterized. Written and oral contracts that

are simple, clear, direct, and time­limited can

be a useful part of the treatment plan.

Contracts can help clients create safe environments for themselves, prevent relapse, or promote appropriate behavior in therapy sessions

and in self­help meetings.

Treatment of people with BPD requires attention to several issues, such as violence to self or

others, transference and countertransference,

boundaries, treatment resistance, symptom

substitution, and somatic complaints.

Key Issues and Concerns in

the Treatment of Borderline

Personality Disorders

•

•

•

•

•

•

•

•

•

•

•

Slow progress in therapy

Suicidal behavior

Self-injury or harming behavior

Client contracting

Transference and countertransference

Clear boundaries

Resistance

Subacute withdrawal

Symptom substitution

Somatic complaints

Therapist well-being

Strategies, Tools, and

Techniques

Engagement

Safety is an anchor for clients with BPD, for

whom abandonment and fear of rejection often

are core issues. Counselors should recognize

that acting­out behavior common to people

with BPD is a maladaptive survivor response

that expresses a need for safety. Indeed, the

client’s primary motivation for treatment may

be a desire for safety. Therapists should discover what safety means to the client.

Soon after entering into a therapeutic alliance,

the reliability of the counselor can have strong

symbolic importance to the client and the

strengthening of the relationship between client

and counselor. Showing up on time, being there

throughout the time period expected, and not

allowing interruptions can have a strong and

positive effect on the client and the client’s

response to treatment. Alternatively, disruptions in the sense of the counselor’s reliability

and trust can have negative fallout. Even what

might seem to the counselor to be a minor event

can be a blow to a client’s shaky emotional

state and interfere with the client–counselor

relationship. The therapist’s absence, even for

brief periods, can prompt acting­out behavior.

Therapists can learn how clients create their

own feelings of safety by asking them about

safe spots, magic getaway places, closet­sitting,

rocking or other repetitive movements, or

other techniques the client may use to generate

a sense of security. To help clients with BPD

establish and maintain a sense of safety, counselors regularly should ask clients: “What do

you need right now?” “What do you want right

now?” Counselors can also help clients to

develop a list of the conditions that they need

to feel safe. Counselors might ask clients,

“What would have been helpful (in a specific

situation) to make you feel safe?” Through

teaching cognitive skills to promote a client’s

sense of safety, counselors can help clients with

BPD assume personal responsibility for their

own safety. (See TIP 36, chapter 4, for a comSpecific Mental Disorders: Additional Guidance for the Counselor 355
plete discussion about counseling issues related

to those clients with BPD and a history of

childhood trauma [CSAT 2000d].)

Written and verbal contracts can identify specific ways to help clients stay safe physically

and emotionally and to prevent relapse.

Contracts for safety should be developed during the assessment process with simple and

clear behavioral responses regarding the management of unsafe feelings and behaviors.

These contracts can be very simple and direct:

• “If I feel like I want to get drunk, I will call

my sponsor.”

• “If I feel like getting high, I will go to the next

NA meeting.”

• “If I feel like hurting myself, I will call a crisis hotline and go to my sister’s house.”

• “I will report self­harm thoughts and behaviors to the therapist at the next session.”

A discrepancy between the client and his or her

clinical record or other source of information

can reflect the client’s inclination to deny, minimize, or hide what the service provider is trying to diagnose. Similarly, few addicted individuals come into an assessment and treatment

planning session prepared to make a full disclosure of their patterns of substance use and the

harm that results

from such use.

Similarly, few individuals with BPD

acknowledge their

maladaptive and

provocative behaviors. Both disorders

are misrepresented

by client self­report

and involve the

client’s insistence

that the real problem lies elsewhere,

usually in how they

are being treated by

others. Diagnosis

and understanding

of both disorders

must come from observation, interpretation,

extrapolation, information from objective

instruments (e.g., assessment tools, urinalysis),

and outside sources (e.g., family).

Progress with	 

clients who have	 

BPD can be slow,

and therapists

should be realistic

in their

expectations.

Screening and assessment 

Gathering historical information affords an

opportunity to examine a client’s strengths and

weaknesses, which are especially important for

clients with BPD. When things are going well,

clients with BPD might have exceptional skills

in various areas. Consequently, a discussion of

what the client sees as weaknesses can be

revealing. Any history of psychotic­like thinking that occurred under intense stress or that

was drug­related should be noted. For example, a client may state, “I really believed the

walls were bleeding.”

The assessment of clients with BPD should elicit any history of self­harm, which is common

among these clients. It is important to explore

when and how such episodes, if any, occurred.

Specifically, determine what is remembered

about the period of time before, during, and

after any episodes of self­harm. A list of potential means available to clients to injure themselves in their own homes, such as a large supply of medication, warrants review for clients

with BPD who have any history of self­harm.

Assessment also should establish any history or

evidence of dissociative experiences, such as

trance states, rocking, flashbacks, or nightmares. Anniversary reactions also are common

to survivors of abuse, whose memories or feelings may be triggered by certain dates, events,

or objects. For no apparent reason, the survivor may become sick or suicidal when faced

with a situation similar to a past reminder of

abuse. The history of fugue states and losing

time may also be significant. For example,

clients with BPD might start watching a movie

and suddenly reorient later in the middle of

another movie, with no clear memory of the

elapsed time.

356 Specific Mental Disorders: Additional Guidance for the Counselor
Crisis stabilization

Safety issues are at the core of crisis stabilization. To ensure the client’s safety or to detoxify a client, a brief psychiatric hospitalization

may be necessary. Issues to be addressed during crisis stabilization might include an unwillingness or inability to contract for safety. A

written release of medical information is

important to coordinate care with physicians

and substance abuse treatment counselors.

At this stage, counselors should avoid psychodynamic confrontations with clients and

should not engage clients in further therapy

for abuse or trauma. The treatment focus

should be on addressing the client’s need for

safety, which is especially important with

clients who have BPD. More complicated and

emotionally charged material should be

deferred until the client has better skills to

manage emotional pain.

It may be helpful to describe out­of­control

crisis behavior as a survivor response.

Counselors and clients should avoid rigid

black­or­white thinking. For example,

describing events or issues as being more or

less helpful may circumvent the inflexibility of

seeing life’s challenges and problems only as

good or bad, while ignoring the numerous

gray areas of experience.

The family should take part in this process. It

may be useful to encourage written and verbal

contracts with family members. These contracts can dissuade family members from

assuming dysfunctional roles such as the victim, the persecutor, and the rescuer. The family should learn how to set boundaries with

the client and avoid playing certain roles,

especially that of rescuer.

Short­term care and 

treatment 

Theorists and clinicians with expertise in PDs

agree that BPD requires long­term, comprehensive, integrated treatment.

Recommendations for the early stages of treatment include developing “skills for managing

negative emotions and memories, such as deep

breathing, using time­outs, and centering

through the senses” (Sullivan and Evans 1994,

p. 374), focusing on emotional regulation,

enhancing motivation, discussing what interferes with treatment (Dimeff et al. 1998), and

carefully considering all medication issues

(including the possible genuine need for assistance with pain control through medication or

other techniques).

Group therapy

There are particular issues of concern when

working with people with BPD in group therapy. Since group counseling regularly begins

early in treatment, counselors should consider

the following group­related issues in both shortand long­term treatment:

• Making contracts for all members to stay in

the room.

• Making contracts for group rules that promote safe behavior.

• Discussing thoughts and feelings about other

group members as they arise.

• Mentioning the time limits at the start of each

session.

• Making mini­contracts for those who have

issues to work on in each session.

• Having group members sign contracts for

abstinence and reporting self­harm and substance use to the group.

• Making contracts for confidentiality.2

2

Confidentiality is governed by the Federal “Confidentiality of Alcohol and Drug Abuse Patient Records” regulations (42

C.F.R. Part 2) and the Federal “Standards for Privacy of Individually Identifiable Health Information” (45 C.F.R.

Parts 160 and 164).

Specific Mental Disorders: Additional Guidance for the Counselor 357
• Disallowing participants to form intimate or

exclusive relationships with one another.

Supportive activities, such as calling one

another during crises or attending 12­Step

meetings together, are acceptable and should

be encouraged.

• Evaluating safety issues in screening people

with BPD for group therapy. Clients should

be safe from the predatory, manipulative

behavior of others, and should not engage in

such behaviors themselves.

• Promoting same­sex groups.

Longer term care

Individual counseling, continuing group therapy, 12­Step participation, and continuum of

care components are the major forms of intervention for comprehensive treatment of clients

with BPD. Dimeff et al. (1998) recommend that

individual and group counseling concentrate on

the development of new skills, balancing toleration of distress with how to change life circumstances (what they see as a “dialectical” interplay of the opposites of an emphasis on change

and an emphasis on acceptance of things as

they are), and targeting specific areas where

control is lacking, such as impulsivity or suicidality.

People with BPD may benefit from skills development in anger management (Reilly et al.

1994). Linehan and colleagues’ (1999) dialectical behavior therapy (DBT) solidly intertwines

group counseling with the unique DBT terminology and therapeutic strategies. Linehan and

her colleagues offer 2­day workshops that train

counselors to use their skills training techniques in leading group counseling for clients

with BPD and substance use disorders.

Individual counseling 

Issues stemming both from BPD and substance

use may emerge in individual therapy. Issues

related to unsafe behavior or substance use will

continue to be important. Longer term care is a

stage in which teaching the client skills such as

assertiveness and boundary setting can be useful.

There is no pressing need for the discussion of

early memories; rather the focus of therapy

should be on behavior (Sullivan and Evans

1994). Complications at this stage can include a

variety of compulsive and impulsive behaviors,

such as eating disorders (obesity, anorexia,

bulimia), compulsive spending and money mismanagement, relationship problems, inappropriate sexual behaviors, and unprotected sex

(in regard to sexually transmitted diseases and

pregnancy). Other maladaptive behaviors

include sexual impulsiveness, which can cause

confusion about sexual identity dramatized in

experimental sexual relationships, adding to

the crisis and drama to which people with BPD

often seem drawn.

Counselors may want to avoid educational

material about adult children of alcoholics or

general self­help books for clients with BPD, as

reading such material may be detrimental to

some clients’ recovery. For some clients, selflabeling can become counterproductive and in

worst­case scenarios, it can lead to self­fulfilling prophecies. For example, books suggesting

that some people self­mutilate in order to

relieve pain may teach clients with BPD to selfmutilate. Some books offering “inner­child

work” lead the client through age­regressive

exercises that can cause an overwhelming flood

of feelings the abused client may not yet be

ready to manage.

Counselors should remember that progress in

treating clients with BPD and substance abuse

problems may be slow and may have many setbacks. Rather than looking for enormous

changes in personality or behavior, counselors

should look for small, observable signs of

improvement.

In addition, counselors may want to consider

the following in treating clients with BPD:

• Use mini­contracts for each session to

encourage the client to stay focused.

• Immediately ask clients about any crises that

have occurred and review the entire week,

not just a particular day.

• State the purpose of each session.

358 Specific Mental Disorders: Additional Guidance for the Counselor
• Run through a checklist that might include

homework, failing tests, arguments with others, interactions with the criminal justice system, problems in school or work life, family

relationships and friends, relapses, thoughts

of self­harm, nightmares, flashbacks, painful

situations, and bad memories. Questions

should be specific.

• Keep and date all correspondence and notes

from telephone conversations. Documenting

conversations can help remind the client of

earlier agreements and conversations.

Mutual self­help group 

participation

Although mutual self­help groups can be

important for clients with BPD, some may not

be able to attend them right away. Some individuals with BPD may find it helpful to participate in self­help group practice sessions. For

example, for clients planning to attend a 12­

Step meeting, they should be helped to organize

their thoughts, to practice saying their name or

“pass” for their first few 12­Step meetings.

Counselors may want to use the step work

handout (see Figure D­7, p. 360) as a treatment

tool for working with people with BPD (see

chapter 7 on the use of 12­Step programs and

the use of other mutual support meetings).

Other mutual self­help groups would require

their own types of preparation.

Because of their problems with intimacy and

trauma, and their own impulsiveness, clients

with BPD should be encouraged to join samesex mutual self­help groups when possible.

People with BPD may find it helpful to use

same­sex sponsors as guides to recovery. When

possible, counselors should educate the sponsor

about survivor behaviors. Since antidepressants or lithium may be an important part of

the client’s recovery, the sponsor might attend

a counseling session to learn why the client is

taking medications. Explaining how medications are helpful can enable sponsors to help

improve medication compliance.

Sponsors who have problems setting boundaries or become overly angry when doing so

should not be paired with clients with BPD. If

such pairing does

occur, the sponsor

needs to understand

how important

boundaries are to

help clients with BPD

feel safe. Understanding this may

keep them from taking on those with
 

BPD, who may be

more than the sponsor can handle.

Material in the step
 

program should be

limited to the hereand­now. As previously stated, clients with
 

BPD should not be
 

asked to address sexual abuse issues until they are ready.
 

Longer term care should include specialized 12­

Step work. In using step one (“We admitted we
 

were powerless over alcohol/our addiction, that
 

our lives had become unmanageable”) with
 

clients who have BPD, counselors should
 

encourage clients to recognize that “powerlessness” does not mean “helplessness.” Instead,
 

clients should focus on gaining personal control
 

over the tools for recovery. Faith and hope
 

concepts used in 12­Step work may also be difficult for this group to comprehend or integrate.
 

Figure D­7 shows a recovery model for treatment of BPD.
 

Issues stemming

both from BPD

and substance use

may emerge in
 

individual
 

therapy.
 

Antisocial Personality

Disorder

Description

The essential diagnostic feature of APD is the

pervasive disregard for and violation of the

rights of others. Since most clients who are

actively using substances display behaviors at

one time or another that show disregard for the

rights of others, it is not surprising that the disSpecific Mental Disorders: Additional Guidance for the Counselor 359
Figure D­7

Step Work Handout for Clients With BPD

Step One: “We admitted we were powerless over alcohol, that our lives had become unmanageable.”

•

•

•

•

Describe five situations where you suffered negative consequences as a result of drinking or using other

drugs.

List at least five “rules” that you have developed to try to control your use of alcohol or other drugs.

(Example: “I never drink alone.”)

Give one example describing how and when you broke each rule.

Check the following that apply to you:

___

___

___

___

___

___

___

___

___

___

I sometimes drink or use drugs more than I plan.

I sometimes lie about my use of alcohol or drugs.

I have hidden or stashed away alcohol or drugs so I could use them alone or at a later time.

I have had memory losses when drinking or using drugs.

I have tried to hurt myself when drinking or using drugs.

I can drink or use more than I used to, without feeling drunk or high.

My personality changes when I drink or use drugs.

I have school or work problems related to using alcohol or drugs.

I have family problems related to my use of alcohol or drugs.

I have legal problems related to my use of alcohol or drugs.

• Give two examples for each item that you checked.

Step Two: “We came to believe that a Power greater than ourselves could restore us to sanity.”

•

•

Give three examples of how your drinking or use of drugs was “insane.” (One definition of insanity is to keep

repeating the same mistake and expecting a different outcome.)

Check which of the following mistakes or thinking errors that you use:

___

___

___

___

___

___

___

___

___

Blaming

Lying

Manipulating

Excuse making

Beating up yourself with “I should have” statements

Self­mutilation (cutting on yourself when angry)

Negative self­talk

Using angry behavior to control others

Thinking “I’m unique”

•

•

•

•

Explain how each thinking error you checked above is harmful to you and others.

Give two examples of something that has happened since you stopped drinking or using drugs that shows

you how your situation is improving.

Who or what is your Higher Power?

Why do you think your Higher Power can be helpful to you?

360 Specific Mental Disorders: Additional Guidance for the Counselor
Figure D­7 (continued)

Step Work Handout for Clients With BPD

Source: Adapted with permission from Evans and Sullivan 1990.

Step Three: “We made a decision to turn our will and our lives over to the care of God as we understood Him.”

•

•

•

•

•

•

Explain how and why you decided to turn your will over to a Higher Power.

Give two examples of things or situations you have “turned over” in the last week.

List two current resentments you have, and explain why it is important for you to turn them over to your

Higher Power.

How do you go about “turning over” a resentment?

What does it mean to turn your will and life over to your Higher Power?

Explain how and why you have turned your will and life over to a Power greater than yourself

Step Four: “We made a searching and fearless moral inventory of ourselves.”

•

•

•

•

•

•

•

•

•

•

List five things you like about yourself.

Give five examples of situations where you have been helpful to others.

Give three examples of sexual behaviors related to your drinking or use of other drugs, which have occurred

in the last 5 years, about which you feel bad.

Describe how beating yourself up for old drinking and drug­using behaviors is not helpful to you now.

List five current resentments you have, and explain how holding on to these resentments hurts your recovery.

List all laws you have broken related to your drinking and use of other drugs.

List three new behaviors you have learned that are helpful to your recovery.

List all current fears you are experiencing, and discuss how working the first three Steps can help dissolve

them.

Give an example of a current situation you are handling poorly.

Discuss how you plan to handle this situation differently the next time the situation arises.

tinction between addictive diseases and APD

has been a difficult one for both the mental

health and the substance abuse treatment

fields.

Individuals with APD exhibit signs of antisocial

behavior from 15 to 18 years of age, such as

unlawful behavior, deceitfulness, consistent

irresponsibility, and lack of remorse. Often

there is evidence of similar behaviors even

before the person turns 15. When antisocial

behavior occurs without any signs of it during

adolescence, the DSM­IV diagnosis is Adult

Antisocial Behavior to distinguish the person

who engages in such behaviors after 18 years of

age—perhaps because of an alcohol­induced

state or the development of substance dependency—from someone with a genuine APD. It

is now widely recognized that “...although

many delinquent youth abuse alcohol as part of

their antisocial behavior, and some become

alcoholic, the majority of alcoholics are not

sociopathic except as a result of their addiction” (Vaillant 1995, p. 88).

One stigmatizing aspect of having a co­occurring APD is that the history of the terms sociopathic, psychopathic, and antisocial carry

extremely negative connotations that might well

be accurate in only a small percentage of those

people with substance use disorders and a current DSM­IV­TR diagnosis of APD. Hare

Specific Mental Disorders: Additional Guidance for the Counselor 361
(1998) differentiates

between more severe

cases of APD by

using the term psychopaths, or

“predators who use

charm, manipulation, intimidation,

and violence to control others and to

satisfy their own

needs” (p. 104).

Hare is careful to

point out that probably only 1 percent

of the general population can be classified as psychopaths

according to his criteria and that most people with antisocial personality disorder are not psychopaths.

Consequently, the number of individuals with

both a co­occurring substance use disorder and

psychopathy is quite small, and substance

abuse treatment counselors are unlikely to see

such clients outside of criminal justice settings

(Hare 1998; Windle 1999). (See also the forthcoming TIP Substance Abuse Treatment for

Adults in the Criminal Justice System [CSAT in

development e] for a full discussion of psychopathy and its relationship to APD.)

More men than women are diagnosed with

APD, although some women with APD may be

misdiagnosed as BPD. Determining the type

and extent of antisocial symptoms for women is

not easy (Rutherford et al. 1999), but it is

important because of the high prevalence of

neglectful parenting in women with substance

use disorders and APD (Goldstein et al. 1999).

The substance abuse

treatment system

encounters many

people with APD

and has developed

effective treatment

methods for them.	 

Substance Use Among People

With APD

Many people with APD use substances in a

polydrug pattern involving alcohol, marijuana,

heroin, cocaine, and methamphetamine. The

illicit drug culture can correspond with their

view of the world as fast­paced and dramatic,

which supports their need for a heightened selfimage. Consequently, they may be involved in

crime and other sensation­seeking, high­risk

behavior. Some may have extreme antisocial

symptoms—for example, rapists with severe

APD may use alcohol to justify conquest, and

the small number of these individuals might

warrant Hare’s designation as psychopaths.

APD appears to be a failure to attach. The

people with this diagnosis appear deficient in

their ability to experience shared or reciprocal

emotions such as guilt or love. Individuals with

APD disdain society’s rules; they know right

from wrong but they do not care. They may be

excited by the illicit drug culture and may have

considerable pride in their ability to thrive in

the face of the dangers of that culture. They

are often in trouble with the law. If they are

more effective, they may limit themselves to

exploitive or manipulative behavior that does

not make them so vulnerable to spending time

in jail.

Key Issues and Concerns

As with co­occurring disorders in general, individuals with both a substance use disorder and

APD have been perceived as exceptionally hard

to treat, having poor prognoses, and warranting exclusion from treatment programs and/or

group counseling.

These negative stereotypes do not hold up well

on examination (Messina et al. 1999). It is true

that as a group substance abuse clients with

APD do worse than substance abuse clients

who do not have APD. Indeed, many articles

begin by correctly describing clients with both

disorders as having a “worse” response to

treatment or a “poor prognosis.” Nonetheless,

research suggests that clients with APD and

substance use disorders can and do respond to

treatment. Seivewright and Daly (1997) note

that clients with APD “progress reasonably satisfactorily in methadone maintenance” (p.

247), and Vaillant (1995) found in his longitudinal study that after 10 to 15 years, 48 percent

of men from an inner­city environment who

had been classified as both alcoholic and socio362 Specific Mental Disorders: Additional Guidance for the Counselor
pathic were abstinent. This is about the same

percentage as an advantaged comparison group

of college men without APD and a significantly

higher percentage than the rate of 28 percent

found in an inner city group of men who

abused alcohol but did not have APD.

The substance abuse treatment system encounters many individuals with substance abuse and

APD and has developed effective treatment

methods for clients with this mental disorder.

Key issues and concerns in the treatment of

people with APD include

• Countertransference and transference

• Counselor/therapist well­being

• Resistance

• Contracting

Countertransference and

transference

In working with clients with APD, countertransference issues might be of equal or greater

concern than transference issues. That is,

although it is usually of more clinical concern

how the client reacts to, interprets, and misinterprets the counselor, when working with

clients with APD, it is also important how the

counselor reacts to, interprets, or misinterprets

the client. Some clients with APD can be frightening to work with; some engage in behaviors

that counselors may reject as criminal and

antisocial; a few have histories of acts that

counselors may abhor. Counselors should be

wary of those clients with APD who can be

charming and underhanded. The reactions of

counselors to working with clients with APD in

general, and each specific client with APD in

particular, requires regular self­examination

and supervision. (Again, the reader is referred

to chapter 4 of TIP 36 [CSAT 2000d].)

Counselor well­being

Counselor well­being is critical for counselors

serving individuals with substance use disorders and APD; counselors who are not provided with an environment that supports a sense

of well­being are subject to burnout. A sense of

well­being can be fostered by the availability of

supervision, the coordination of duties in a

team structure, and a clear understanding of

roles and responsibilities for standard and crisis situations.

Carlson and Baker (1998) report briefly on

efforts at the Portland Veterans Affairs Medical

Center to establish a system to assist staff and

improve care when managing clients who are

dangerous, difficult, demanding, or drug­seeking. They describe a coordinated and focused

approach with multidisciplinary meetings of

administrators, clinicians, and others that

serve to support consistent and systemwide

methods of handling these types of situations.

In examining 36 consecutive cases under the

system, they noted that the 36 individuals committed 47 incidents of violence during the year

prior to the implementation of their program,

whereas the number of incidents dropped to 4

in the year following implementation.

Moreover, their evaluations documented

increased staff morale and confidence.

Although not specifically targeting clients with

substance use disorders and APD, their coordinated, top­to­bottom system for team­handling

such stressful client–staff interactions is applicable to these clients.

Resistance

Clients with APD are often said to “act out”

tension or conflict. Behaviors that interfere

with treatment, which might even result in a

client being sent immediately to jail, are seen

by therapists as a form of resistance to whatever happens to be the focus of therapy at the

time. Substance abuse treatment counselors

working with clients with APD often sense

resistance to substance abuse treatment and its

goals. The counselor should not buy into this

negative or pessimistic outlook. Instead, counselors can focus on how much better the client’s

life will be with successful treatment, and

explain to the client that treatment can succeed

without the client’s complete commitment at the

beginning.

Specific Mental Disorders: Additional Guidance for the Counselor 363
It can be hard for a counselor not to blame the

client for failing to seek a better life and better

behavior. Counselors who fall into this countertransference reaction expect that the client simply has a choice he fails to make. Interestingly,

some research (Raine et al. 2000) shows lower

prefrontal gray matter volumes in clients with

APD (compared to healthy controls, individuals with substance dependence, and other mental disorders). Thus, the extent of actual control clients with APD have over their responses

and resistance might well be less than others

due to this physiological deficit.

Contracting

Contracting is essential in working with clients

with APD. Without contracts and clear expectations of what is to be done, when, how, and

the consequences of failing to comply, the therapeutic relationship can become a constant

argument about why something was not done

and why it is unfair to be punished for an

infraction or omission. As a general rule, when

working with individuals with substance use

disorders and APD, it is advised to put everything into writing.

Strategies, Tools, and

Techniques

Engagement

In engaging the client with APD, it is useful to

remain neutral toward the client’s world view,

which may include a need for control and a

sense of entitlement. In this context, entitlement refers to people who believe their needs

are more important than the needs of others.

Entitlement may include rationalization of negative behavior (such as robbery or lying).

People with APD may evidence little empathy

for their victims. If incarcerated, they may

believe they should be released immediately. In

a substance abuse treatment program, they

may describe themselves as being unique and

requiring special treatment.

The primary motivation of the client with APD

is to be right and to be successful. It is useful to

work with this motivation, not against it.

Although this motivation may not reflect socially acceptable reasons for changing behavior, it

does offer a point from which to begin treatment. Wanting to be clean and sober, to keep a

job, to avoid jail, and to become the chair of an

Alcoholics Anonymous (AA) meeting are reasonable goals, despite a self­serving appearance. Counselors can help clients with APD by

working with clients’ world views, rather than

by trying to change their value systems to

match those of the therapist or of society. Of

course, in therapeutic communities the expectation of eventually having a change in values

and in self is part and parcel of the structure of

the community, but early in a client’s treatment

those aspects of the program might well be kept

on the “back burner.”

Contracting is another effective strategy.

Contracts establish rules for conduct during

treatment and clarify the clients’ role in the

therapeutic process. The contract should state

explicitly all expectations and rules of conduct

and should be honored by all parties. Such an

approach can be useful with people with APD,

who often view relationships as unfair contracts in which one person attempts to take

advantage of the other. Counselors may find

that once a level of interpersonal respect has

been established, working with antisocial

clients can lead to important gains for the

client.

Screening and assessment

In addition to an objective psychosocial and

criminal history, the following steps may be

useful in assessing the antisocial client:

• Taking a thorough family history.

• Finding out whether the client set fires as a

child, abused animals, or was a bed­wetter.

• Taking a thorough sexual history that

includes questions about animals and objects.

Asking about any unusual or out­of­the­ordinary sexual experiences may serve as a lead364 Specific Mental Disorders: Additional Guidance for the Counselor
in and as a means to gauge how the client

responds to questions about such personal

areas.

• Taking a history of the client’s ability to bond

with others. Counselors can ask, “Who was

your first best friend?” “When was the last

time you saw him or her?” “Do you know

how he or she is?” “Is there any authority

figure who has ever been helpful to you?”

• Asking questions to find out about possible

parasitic relationships and taking a history of

exploitation of self and others. In this context, parasitic refers to a relationship in

which one person uses and manipulates

another until the first has gotten everything

he or she wants, then abandons the relationship.

• Taking a history of head injuries, fighting,

and being hit. It may be useful to refer for

neuropsychological testing.

• Testing urine for recent substance use.

• HIV testing.

The assessment should consider criminal thinking patterns, such as rationalization and justification for maladaptive behaviors. There is a

special need to establish collateral contacts and

to assess for criminal history and the relationship of substance use to behavior. Useful

assessment instruments include

• The Minnesota Multiphasic Personality

Inventory ­ 2 (MMPI­2)

• The Millon Clinical Multiaxial Inventory

(MCMI), and Nadeau et al. 1999

• The PCL­R (Hare Psychopathy ChecklistRevised), and the forthcoming TIP

Substance Abuse Treatment for Adults in the

Criminal Justice System (CSAT in development e)

Crisis stabilization

People with APD may enter treatment profoundly depressed, feeling that all systems have

failed them. Often, their scams and lofty ideas

have failed. They feel exposed and have no ego

strength. They are at risk for suicide, especially during intoxication or acute withdrawal, and

may require psychiatric hospitalization and

detoxification. Containment in the form of a

brief hospitalization may be indicated for

clients experiencing acute paranoid reactions to

avoid acting out against others. When paranoid

reactions are less acute, counselors should

avoid cornering clients, disengage from any

power struggle, offer lower stimulus levels, and

explore options, especially those suggested by

the client. During this phase, clarification without harsh confrontation is recommended.

Counselors should be especially cautious when

working with APD clients in crisis. These

clients may engage in dangerous physical

behavior to avoid unpleasant situations or

activities. Counselors are advised avoid angry

confrontations.

In engaging the

client with APD, it

is useful to remain

neutral toward the

client’s world view.

Short­term care and 

treatment

O’Connell (1998, pp. 123–124), acknowledging

the historical contributions of Doren (1987)

and Barley (1986), advises counselors to be

prepared to be “amused by these clients, outraged by their lack of conscience, intrigued

with the glamour of their high­risk lifestyle, or

flattered by their praise of the therapist’s skills

and knowledge ...

excessively fascinated

by the course of therapy.” He recommends

developing strategies

to (1) get reliable

information from others to counter misrepresentation of facts,

(2) avoid being

manipulated or having any intense interest in any of the

client’s escapades or

old war stories, and

(3) confront intimidation, criticism, and

flattery through

supervision and/or a

Specific Mental Disorders: Additional Guidance for the Counselor 365
team approach. Confronting antisocial behavior and its relationship to substance use is, of

course, an ever­present part of treating clients

with substance use disorders and APD.

Group therapy

In group therapy, clients with APD can learn

to identify errors not only in their own thinking

but in the thinking of others, as well as thinking that makes them vulnerable to relapse. For

example, when an individual begins to glamorize stories of substance use or criminal and acting­out behaviors, the group can help to limit

that grandiosity. Counselors may also ask people with APD to discuss feelings associated with

the behavior being glamorized.

Clients with APD may be asked to sign contracts that establish healthy and nonparasitic

relationships with other group members. This

means not becoming romantically involved with

other members, not borrowing money from

them, and not developing exploitive relationships. Role­play exercises can be useful tools in

group counseling; however, counselors should

be careful to prevent clients with APD from

using newly learned skills to exploit or control

other group members. In group therapy, clients

with APD can be encouraged to model prosocial behaviors and to learn by practicing them.

Role­play exercises can help these clients focus

on their own shortcomings rather than on the

faults of others.

Greene and McVinney (1997) describe anger,

group cohesion, dependency/counterdependency, and overdeveloped/underdeveloped strategies as significant areas requiring the counselor’s attention when running outpatient

groups for male clients with Cluster B personality disorders and chemical dependency. They

emphasize the importance of interrupting anger

and hostility early in group formation by

encouraging the clients to “talk through the

therapist” rather than directly to each other,

and by having members learn to monitor triggers and understand why some behaviors elicit

a hostile response. Group cohesion can be

threatened unless clients with PD also have

individual counseling that helps them manage

their reactions to the group and group membership. For clients with APD, issues related to

dependency and counterdependency are likely

to be long­term group issues, and group work

will focus on overdeveloped combativeness,

exploitiveness, and predation and underdeveloped strategies of empathy, reciprocity, and

social sensitivity. Many theorists and clinicians

employ cognitive–behavioral and “reality therapy” orientations for clients with APD, both

with and without substance use disorders.

Fisher (1995) offers an outline of Group

Leadership Actions for a 4­week, 15­session

cognitive–behavioral therapy group for clients

with substance use disorders and APD.

Longer term care

Individual counseling

It is helpful to view working with clients with

APD as a process of adaptation of thinking,

rather than the restructuring of a client into a

person whose morals and values match those of

the therapist or society. Counselors may benefit

from modifying their own expectations of treatment outcomes, realizing that they may not be

able to help certain clients develop empathic

and loving personalities—it is enough to guide

clients to lead lives that follow society’s rules.

Figure D­8 offers tips for counseling clients

with APD.

Individual counseling offers the counselor an

opportunity to point out clients’ errors in

thinking without causing them to feel humiliated in the presence of the group. Other issues

for individual counseling may include continued relapse management and identity of empathy. Three key words summarize a strategy for

working with people with APD: corral, confront, and consequences.

1. Corral. Corralling with regard to clients

with APD means coordinating treatment with

other professionals, establishing a system of

communications with other professionals and

with clients, contracting clients to be responsible for their substance use in the recovery program, monitoring information about clients,

and working toward specific treatment goals.

366 Specific Mental Disorders: Additional Guidance for the Counselor
Clients may benefit by signing agreements to

comply with the treatment plan and by receiving written clarification of what is being done

and why. Interventions and interactions should

be linked to original treatment goals. One

approach to treatment that adds to the notion

of “corralling” is to “expand the system.”

Spouses, family members, friends, and treatment professionals may be invited to participate in counseling sessions as a way to provide

collateral data. This is sometimes called “network therapy.”

2. Confront. In confronting clients who are

antisocial, counselors can be direct and firm.

They can be clear in pointing out antisocial

thinking patterns. They can remark on contradictions between what clients say and what

clients do. Random testing for substances is

essential for monitoring clients with APD.

Honest reporting of substance use should be an

active part of treatment.

3. Consequences. Clients should bear the

responsibility for the consequences of their

behavior. For instance, violation of probation or

rules should be recorded. Clients who are

offenders should be encouraged to report behavior that violates probation, thus taking responsibility for their own actions. Positive consequences that demonstrate to clients the benefits

of appropriate behavior should also be designed

and incorporated into the treatment plan.

Case management

Case management may involve coordinating

care with a variety of other professionals and

individuals, including those in the criminal justice system, mental health providers, and family members. Clients need to understand that

the counselor must talk to other providers and

to family members. It is helpful for clients to

sign consents for the release of information for

all people involved in their treatment.

Terminating counseling

The question of terminating counseling can be

puzzling for counselors treating clients with

APD. Clients with APD frequently express a

desire to end treatment. This desire should be

closely examined to determine whether it is a

manifestation of client resistance or a valid

request. Reasons for termination on the counselors’ part can include noncompliance with

treatment, continued drug use without

improvement, any aggressive behavior, paraFigure D­8

Counseling Tips for Clients With APD

Corral: •

•

•

Coordinate treatment.

Communicate with other providers.

Make contracts with clients.

Confront: •

•

•

Be direct and firm.

Identify antisocial thinking.

Conduct random substance testing.

Consequences: •

•

•

•

Make clients responsible for their behavior.

Record violations of rules.

Allow clients to experience consequences of their behavior.

Designate positive consequences for prosocial behavior.

Specific Mental Disorders: Additional Guidance for the Counselor 367
Figure D­9

Antisocial Thinking­Error Work

Adapted with permission from Evans and Sullivan 1990.

The group facilitator presents thinking errors and then asks each group member to identify two thinkingerror examples that apply to him or her and to choose one to focus on with the group’s help.

1.

2.

3.

4.

5.

6.

7.

8.

9.

Excuse making. Excuses can be made for anything and everything. Excuses are a way to justify behavior.

For example: “I drink because my mother nags me,” “My family was poor,” “My family was rich.”

Blaming. Blaming is an excuse to avoid solving a problem and is used to excuse behavior and build up

resentment toward someone else for “causing” whatever has happened. For example: “They forced me to

drink it!”

Justifying. To justify an antisocial behavior is to find a reason to support it. For example: “If you can, I

can,” “I deserve to get high, I’ve been clean for 30 days.”

Redefining. Redefining is shifting the focus on an issue to avoid solving a problem. Redefining is used as a

power play to get the focus off the person in question. For example: “I didn’t violate my probation. The

language is confusing and the order is full of typos.”

Superoptimism. “I think; therefore it is.” Example: “I don’t have to go to AA. I can stay sober on my own.”

Lying. There are three basic kinds of lies: (1) lies of commission, or making things up that are simply not

true; (2) lies of omission, or saying partly what is true but leaving out major sections; and (3) lies of

assent, or pretending to agree with other people or approving of their ideas despite disagreement or having no intention of supporting the idea.

“I’m unique.” Thinking one is special and that rules should not apply to oneself.

Ingratiating. Being nice to others, and going out of one’s way to act interested in other people, can be used

to try to control situations or get the focus off a problem. Also known as “apple polishing.”

Fragmented personality. Some people may attend church on Sunday, get drunk or loaded on Tuesday, and

then attend church again on Wednesday. They rarely consider the inconsistency between these behaviors.

They may feel that they have the right to do whatever they want and that their behaviors are justified.

10.

11.

Minimizing. Minimizing behavior and action by talking about it in such a way that it seems insignificant.

For example: “I only had one beer. Does that count as a relapse?”

Vagueness. This strategy is to be unclear and nonspecific to avoid being pinned down on any particular

issue. Vague words or phrases such as: “I more or less think so,” “I guess,” “Probably,” “Maybe,” “I

might,” “I’m not sure about this,” “It possibly was,” etc.

12.

13.

14.

15.

Power play. This strategy is to use power plays whenever one isn’t getting one’s way in a situation.

Examples include walking out of a room during a disagreement, threatening to call an attorney or to

report the group facilitator to higher­ups.

Victim playing. The victim player transacts with others to invite either criticism or rescue from those

around him.

Grandiosity. Grandiosity is minimizing or maximizing the significance of an issue, and it justifies not solving the problem. For example: “I was too scared to do anything else but sit,” “I’m the best there is, so no

one else can get in my way.”

Intellectualizing. Using an emotionally detached, data­gathering approach to avoid responsibility. For

example, when faced with a positive urine drug screen the client states, “When was the last time the laboratory had its equipment calibrated?” or “What is the percentage of error in this testing procedure?”

368 Specific Mental Disorders: Additional Guidance for the Counselor
sitic relationship with other clients, or any

unsafe behavior.

Breaking the rules

Clients with APD compulsively try to break

rules. If a treatment plan is not devised to work

with a person who wants to redefine rules, termination should be considered and transfer to

more appropriate care arranged.

Continuum of care

A key to treating people with APD is to be flexible within an array of containment interventions. Counselors should have the ability to

move a client quickly from a less controlled

environment to a more controlled environment.

Clients benefit from sanctions that match the

degree of severity of behavior. Sanctions should

not be “punishments” but responses to the

need for containment and more intensive treatment. Clients with APD need a range of treatment and other services, from residential to

outpatient treatment, from vocational education to participation in long­term relapse prevention support groups, and from jail to 12­

Step programs.

Thinking­error work

Continued thinking­error work, as described in

Figure D­9, may help clients identify various

types of rationalizations that they may use

regarding their behaviors. Ball (1998) and Ball

and Young (2000) developed a 24­week manual

guided cognitive–behavioral approach for people with substance use and PDs; research with

an opioid­dependent group is being supported

by NIDA.

Mood and Anxiety

Disorders

Description

Mood disturbance and anxiety are ever­present

features of many people in treatment for substance use disorders. A substance­abusing

lifestyle regularly brings with it great cause for

worries and sadness. Often, in recovery, these

negative feeling states are, in time, replaced

with hopefulness, a sense of renewal, and a

general level of well­being. Many substances

also cause mood and anxiety disorders through

biochemical changes that may be alleviated

when the client is no longer using. Sometimes,

however, clients have anxiety and/or mood disorders that require treatment, both for their

resolution and to remove the threats to recovery associated with these disorders.

Mood episodes

A mood episode is a cluster of symptoms that

occur together for a discrete period of time,

including

• Changes in appetite or weight, sleep, and

psychomotor activity. The individual may

report loss of interest in eating or may crave

foods such as sweets or carbohydrates; the

person may seem agitated or action may seem

slowed down—for example, slowed speech

and body movements. Frequently, the person

has difficulty sleeping or sleeps too much.

Waking up 90 minutes to 2 hours before

usual and being unable to go back to sleep

(“early morning awakening”) and difficulty

falling asleep are common manifestations of

sleep problems.

• Decreased energy. Sometimes the person also

reports decreased efficiency in performing

tasks.

• Feelings of worthlessness or guilt. The individual may be preoccupied with past feelings

and dwell on personal defects, often with cognitive distortion such as strong feelings of not

living up to her or his potential even though

the person has been very productive and others think well of her or his work.

• Difficulty thinking, concentrating, or especially making decisions. Sometimes people

are easily distracted, have difficulty with

memory, or perform normally but feel that it

requires increased effort to do so.

• Recurrent thoughts of death, suicidal

ideations, and/or suicidal plans or attempts.

Specific Mental Disorders: Additional Guidance for the Counselor 369
Mood disorders

Bipolar I, bipolar II, and

cyclothymia

While Bipolar I and II are classified in the

DSM­IV as mood disorders, mania and bipolar

disorders are addressed in the next section on

schizophrenia and psychosis. The fundamental

difference diagnostically between bipolar I and

bipolar II disorders relates to whether the individual has experienced a manic episode. If a

person has never experienced a manic episode,

but has both periods of major depression and

periods of at least 4 days of hypomanic states,

the diagnosis is one of bipolar II disorder.

Though seemingly minor, the difference carries

considerable prognostic value—people who

experience a true manic episode along with

alternating episodes of major depression have

an extremely high probability of having another manic episode. Usually, the manic episode

will occur immediately before or immediately

after a major depressive episode (APA 2000).

Thus, what can seem to be a small diagnostic

matter can be significant, and in this case it is

likely that bipolar I and bipolar II represent

meaningfully distinct clinical entities.

Cyclothymic disorder is a mood disorder that

involves fluctuating moods from above normal

to below normal, but never has symptoms so

severe or persistent as to meet the diagnostic

criteria for a bipolar disorder. To be considered a disorder, the disturbance must reach a

level great enough to have a negative impact on

someone’s interpersonal or vocational life.

With a co­occurring substance use disorder, all

forms of mood disorders can worsen acutely

over the long run.

Major depression

Symptoms of major depression may occur at

mild or moderate levels of severity. Major

depression typically is experienced as a more

intense and acute depression, often with strong

physiological changes in appetite, sleep, energy

level, and ability to think, as well as excessive

feelings of worthlessness with possible suicidal

ideation or plans. Though two thirds of people

who experience a major depressive episode

recover fully (APA 2000), one third may recover only partially and a number of individuals

develop a persistent major depressive disorder,

often meeting criteria for evidence of severe

and/or persistent mental illness.

Severe depressive episodes can include psychotic features, such as an auditory hallucination of a voice saying that the person is “horrible,” a visual hallucination of a lost relative

mocking the person, or a delusion that one’s

internal body parts have rotted away.

However, most people who have a major

depressive episode do not exhibit psychotic

symptoms even when the depression is severe

(for more information see the next section on

schizophrenia and psychosis).

Chapter 8 contains a full description of the

characteristics of a Major Depressive Episode.

Dysthymia and generalized

anxiety disorder (GAD)

GAD and dysthymia are, respectively, prevalent anxiety and mood disorders. Both are persistent disorders. GAD is characterized by at

least 6 months of persistent and excessive anxiety and worry (APA 2000). Dysthymic disorder

“is characterized by a depressed mood for most

of the day, for more days than not, for at least

2 years” (APA 2000, p. 380). Dysthymic symptoms can include feelings of inadequacy, loss of

interest and social withdrawal, irritability,

excessive anger, and lethargy. At some time in

their lives 5 percent of people will have GAD

and 6 percent will have dysthymic disorder

(APA 2000). Consequently, substance abuse

counselors need to be alert to GAD or dysthymic disorder in their clients. The term anxiety refers to the sensations of nervousness, tension, apprehension, and fear. In GAD there is

no specific focus to the anxiety—it is said to be

“free­floating.” Other common anxiety disorders are panic disorder, specific phobia, and

social phobia; obsessive­compulsive disorder;

and PTSD and acute stress disorder.

370 Specific Mental Disorders: Additional Guidance for the Counselor
Anxiety disorders

Panic attack, panic disorder, specific phobia, and social phobia

A panic attack is a distinct period of intense

fear or discomfort that develops abruptly, usually reaching a crescendo within a few minutes

or less. Physical symptoms may include hyperventilation, palpitations, trembling, sweating,

dizziness, hot flashes or chills, numbness or

tingling, and the sensation or fear of nausea or

choking. Psychological symptoms may include

depersonalization and derealization (feeling as

if things are not real) and fear of fainting,

dying, doing something uncontrolled, or losing

one’s mind.

A panic disorder consists of episodes of panic

attacks followed by a period of persistent fear

of the recurrence of more panic attacks.

Sometimes panic attacks are associated with

fears of going places where rapid exit would be

difficult or embarrassing, such as over bridges,

in airplanes, or in stores or markets. When the

focus of anxiety is an activity, person, or situation that is dreaded, feared, and probably

avoided, the anxiety disorder is called a phobia. Panic disorders often are underdiagnosed

at the beginning of treatment, or else are seen

as secondary to the more significant disorders,

which are the primary focus of treatment.

However, panic disorders can impede significantly a person’s ability to do the tasks of

recovery, such as getting on a bus to go to a

meeting or sitting in a 12­Step meeting.

Sometimes these can erroneously be identified

as manipulative or treatment­resistant behaviors.

Phobia­inspired avoidance behavior, with its

associated travel and activity restrictions, may

become intense and incapacitating. The phobias include agoraphobia, social phobia, and

simple or specific phobia; panic attacks and

panic disorders often are involved, but not necessarily. Specific phobia, also called single or

simple phobia, describes the onset of intense,

excessive, or unreasonable fear stimulated by

the presence or anticipation of a specific object

or situation. The causes may be naturally

occurring (e.g., animals, insects, thunder,

water), situational (such as heights or riding in

elevators), or related to receiving injections or

giving blood. Social phobia describes the persistent and recognizably irrational fear of

embarrassment and humiliation in social situations. The social phobia may be quite specific

(e.g., public speaking) or may become generalized to all social situations.

Though panic disorders, phobias, and

social phobias may

seem relatively

straightforward, they

are quite complex, as

they often are historically intertwined for

each and every person. For example, the

client who says he or

she is “claustrophobic” and fears getting

into an elevator may

have had a few panic

attacks 20 years

beforehand, has successfully avoided
 

going into any elevators in the past 2
 

decades, and may barely remember the panic
 

symptoms associated with the original reaction
 

to elevators that led to the avoidant behavior.
 

There is considerable evidence that both nonmedication behavioral approaches and medications can be useful, either alone or in combination in the treatment of these mental disorders.
 

Mood disturbances

and anxiety are

ever­present

features of many

people in

substance abuse

treatment.

Obsessive­compulsive disorder

(OCD)

OCD is an anxiety disorder involving obsessions or compulsive rituals, or both. Obsessions

are repetitive and intrusive thoughts, impulses,

or images that cause marked anxiety. They

often involve transgressing social norms, harming others, and becoming contaminated, but

they are more intense than excessive worries

about real problems. Compulsions are repetitive rituals and acts that people are driven to

perform and which they perform reluctantly to

Specific Mental Disorders: Additional Guidance for the Counselor 371
prevent or reduce distress. The frequency and

duration of their repetition make them inconvenient and often incapacitating. Examples

include ritualistic behaviors (such as hand

washing and rechecking) and mental acts (e.g.,

counting and repeating words silently).

Obsessions are often time consuming and interfere significantly with daily functioning.

PTSD and acute stress disorder

Although PTSD is one of the anxiety disorders

and many of the possible symptoms of PTSD

are anxiety­like symptoms, PTSD has been

identified as so prevalent in populations with

COD that it is described in full in the following

section. There is only a diagnostic difference

between PTSD and acute stress disorder in

that PTSD cannot be diagnosed until and

unless a person experiences the symptoms for a

month; therefore, if the symptoms last less than

1 month or it has been less than 1 month since

the traumatic event, then acute stress disorder

rather than PTSD would be diagnosed.

Except for these timeframe criteria, the symptoms of acute stress disorder that follow a traumatic event are, by and large, the same types of

symptoms as PTSD. The client may have a

subjective sense of “being in a daze” with emotional detachment, inability to recall aspects of

the event, feeling as if things are not real (derealization), feeling that one is not oneself or disconnected from feeling oneself (depersonalization). The client may also report the phenomena of re­experiencing the event, avoidant

behavior, increased arousal, distress, and

interference with functioning. See the section

on PTSD for a thorough description.

Differential Diagnosis

It comes as no surprise to the substance abuse

treatment counselor that licit and illicit drugs

of abuse cause symptoms that are identical to

the depression and anxiety symptoms that have

been discussed. In addition, many medications,

toxins, and medical procedures can cause or

are associated with an eruption of an anxiety

and/or depressive reaction. Moreover, these

reactions run the gamut from mild manifestations of short­lived symptoms to full­blown

manic and other psychotic reactions, which are

not necessarily short­lived.

For substance abuse counselors and clinicians,

the role of personality, preexisting mood state,

personal expectations, drug dosage, and environmental surroundings all warrant consideration in developing an understanding of how a

particular client might experience a substanceinduced disorder. While many people with substance use disorders will experience sensory

and perceptual distortions, some will experience euphoric religious or spiritual states that

may resemble aspects of a manic or psychotic

episode. Others may have a deeply troubling

introspective experience, causing symptoms of

depression. Some may have a positive experience that they seek to repeat.

Diagnostic process

Diagnoses of mental disorders should be provisional and reevaluated constantly. Many

apparent mental disorders are really substance­induced disorders that are caused by

substance use. Treatment of the substance use

disorder and an abstinent period of weeks or

months may be required for a definitive diagnosis of an independent, co­occurring mental

disorder. As described in chapter 4 on assessment, substance abuse treatment programs and

clinical staff can concentrate on screening for

mental disorders and determining the severity

and acuity of symptoms, along with an understanding of the client’s support network and

overall life situation.

Anxiety and mood disturbance in other disorders

Anxiety and mood disturbance, often a regular

part of the life of people with substance use disorders, are common, ubiquitous components of

almost all mental disorders. People with

schizophrenia or PDs, for example, typically

experience ups and downs in anxiety, as well as

waxing and waning of mood disturbance.

Therefore, not only is it difficult to tell when

372 Specific Mental Disorders: Additional Guidance for the Counselor
someone enters substance abuse treatment

whether the person has a co­occurring mood or

anxiety disorder that is separate from the substance use disorder, it is also hard to determine

whether the symptoms of mood or anxiety disorders are part of the manifestations of another mental disorder or constitute a separate disorder.

Many psychiatric conditions can mimic mood

disorders. Disorders that can complicate diagnosis include schizophrenia, brief reactive psychosis, and anxiety disorders. Clients with

PDs, especially of the borderline, narcissistic,

and antisocial types, frequently manifest symptoms of mood disorders. These symptoms often

are fluid and may not meet the diagnostic criterion of persistence over time. In addition, all of

the mental disorders noted here can coexist

with substance use and mood disorders.

To make the initial evaluative situation even

more challenging, discriminating between an

acute anxiety disorder and an acute mood disorder can be difficult. Of course, where severe

and acute symptoms exist, treatment personnel

move ahead with treatment for all the presenting problems while awaiting the ultimate resolution over time of the diagnostic specifics. As

noted in chapter 4, this is a major reason to

repeat screening and assessment periodically as

recovery proceeds.

Anxiety and mood disturbances versus substance use

Symptoms that look like anxiety or mood disturbances may appear either during use or

withdrawal. Withdrawal from depressants, opioids, and stimulants invariably includes potent

anxiety symptoms (see Figure D­10). During

the first months of abstinence, many people

with substance use disorders may exhibit symptoms of depression that fade over time and are

related to acute withdrawal. Since depressive

symptoms during withdrawal and early recovery may result from substance use disorders

and not an underlying depression, a period of

time should elapse before depression is diagnosed. Overall, the process of addiction per se

can result in biopsychosocial disintegration,

leading to chronic dysthymia or depression

often lasting from months to years.

Acute manic symptoms may be induced or

mimicked by intoxication with stimulants,

steroids, hallucinogens, or polydrug combinations. They may also be caused by withdrawal

from depressants such as alcohol. Individuals

experiencing acute mania with its accompanying hyperactivity, psychosis, and often aggressive and impulsive behavior should be referred

to emergency mental health professionals. This

is true whatever the causes may appear to be.

Substance­induced mood alterations can result

from acute and chronic drug use as well as

from drug withdrawal. Substance­induced

mood disorders, most notably acute depression

Figure D­10

Drugs That Precipitate or Mimic Mood Disorders

Mood Disorders During Use (Intoxication) After Use (Withdrawal)

Depression and dysthymiaAlcohol, benzodiazepines, opioids, barbiturates, cannabis, steroids (chronic), stimulants (chronic)Alcohol, benzodiazepines, barbiturates,

opioids, steroids (chronic), stimulants

(chronic)

Mania and

cyclothymia

Stimulants, alcohol, hallucinogens,

inhalants (organic solvents), steroids

(chronic, acute)

Alcohol, benzodiazepines, barbiturates,

opioids, steroids (chronic)

Specific Mental Disorders: Additional Guidance for the Counselor 373
lasting from hours to days, can result from

sedative­hypnotic intoxication. Similarly, prolonged or subacute withdrawal, lasting from

weeks to months, can cause episodes of depression, and sometimes is accompanied by suicidal

ideation or attempts. Figure D­10 provides an

overview of drugs that precipitate or mimic

mood disorders.

Stimulant withdrawal

Stimulant withdrawal may provoke episodes of

depression lasting from hours to days, especially following high­dose, chronic use. Stimulantinduced episodes of mania may include symptoms of paranoia lasting from hours to days.

Stimulants such as cocaine and amphetamines

cause potent psychomotor stimulation.

Stimulant intoxication generally includes

increased mental and physical energy, feelings

of well­being and grandiosity, and rapid pressured speech. Chronic, high­dose stimulant

intoxication, especially when combined with

sleep deprivation, may prompt an episode of

mania. Symptoms may include euphoric,

expansive, or irritable mood, often with flight

of ideas, severe impairment of social functioning, and insomnia.

Acute stimulant withdrawal generally lasts

from several hours to 1 week and is characterized by depressed mood, agitation, fatigue,

voracious appetite, and insomnia or hypersomnia (oversleeping). Depression resulting from

stimulant withdrawal may be severe and can be

worsened by the individual’s awareness of substance­abuse–related adverse consequences.

Symptoms of craving for stimulants are likely

and suicide is possible.

Protracted stimulant withdrawal often includes

sustained episodes of anhedonia (absence of

pleasure) and lethargy with frequent ruminations and dreams about stimulant use. There

may be bursts of dysphoria, intense depression, insomnia, and agitation for several

months following stimulant cessation. These

symptoms may be either worsened or lessened

by the quality of the client’s recovery program.

Mood and anxiety disorders

versus medical conditions

and medication­induced

symptoms

Medical problems and medications can produce

symptoms of anxiety and mood disorders. For

example, acute cardiac disorders can produce

symptoms that suggest generalized anxiety or

panic disorders. Similarly, both prescribed and

over­the­counter medications can precipitate

depression. Diet pills and other over­thecounter medications can lead to mania. It is

important to distinguish between the symptoms

of a mental disorder and those accompanying a

medical disorder or those associated with an

over­the­counter or prescription medication.

The counselor should be aware of these possibilities and seek information that helps make

an accurate determination.

Prevalence

Approximately one quarter of U.S. residents

are likely to have some anxiety disorder during

their lifetime, and the prevalence is higher

among women (30.5 percent) than men (19.2

percent) (Kessler et al. 1994). Estimates of lifetime prevalence for major depression range

from 10 to 25 percent for women and half that

for men. For dysthymic disorder, estimates are

6 percent for both women and men (APA

2000).

Data from the National Comorbidity Study

indicate that about one half (41 to 65 percent)

of individuals with a substance use disorder

have an affective or anxiety disorder at some

time in their lives (Kessler et al. 1996b). Among

women with a substance use disorder, mood

disorders may be prevalent, and women are

more likely than men to be clinically depressed

and/or to have PTSD. Research suggests that

4.5 percent of clients with substance use disorders have panic disorder and 16 percent of

panic disorder clients have a co­occurring substance use disorder (DuPont 1997).

374 Specific Mental Disorders: Additional Guidance for the Counselor
Assessment Case Studies: George M. and Teresa G.

George M.

George M. is a 37­year­old divorced male who was brought into the emergency room intoxicated. His blood

alcohol level was .152, and the toxicology screen was positive for cocaine. He was also suicidal (“I’m going to

do it right this time!”). He has a history of three psychiatric hospitalizations and two inpatient substance

abuse treatments. Each psychiatric admission was preceded by substance use. George M. has never followed

through with psychiatric treatment. He has intermittently attended AA, but not recently.

Teresa G.

Teresa G. is a 37­year­old divorced female who was brought into a detoxification unit with a blood alcohol

level of .150. She was observed to be depressed and withdrawn. She has never used drugs (other than alcohol), and began drinking alcohol only 3 years ago. However, she has had several alcohol­related problems

since then. She has a history of three psychiatric hospitalizations for depression, at ages 19, 23, and 32. She

reports a positive response to antidepressants. She is currently not receiving mental health services or substance abuse treatment.

Differential diagnostic issues for case examples. Many factors must be examined when making initial diagnostic and treatment decisions. For example, if George M.’s psychiatric admissions were 2 or 3 days long, usually

with discharges related to leaving against medical advice, decisions about diagnosis and treatment would be

different if than if two of his psychiatric admissions were 4 to 6 weeks long with clearly defined manic and

psychotic symptoms continuing throughout the course, despite aggressive use of psychiatric treatment and

medication.

Similarly, if Teresa G. had abstained from alcohol for 6 months “on her own,” had relapsed the night before

while thinking about killing herself, had become increasingly depressed and withdrawn over the past 3

months, and had suffered from disordered sleep, poor concentration, and suicidal thoughts, a different

diagnostic picture would emerge.

Certain populations are at risk for anxiety and

mood disorders. American Indians, clients with

HIV, clients maintained on methadone, and

older adults may all have a higher risk for

depression. The elderly may be the group at

highest risk for combined mood disorder and

substance problems (see TIP 26, Substance

Abuse Among Older Adults [CSAT 1998d]).

Episodes of mood disturbance generally

increase in frequency with age. Older adults

with concurrent mood and substance disorders

tend to have more mood episodes as they get

older, even when their substance use is controlled. Also, from 20 to 25 percent of individuals who have chronic or severe general medical

conditions, such as diabetes or stroke, develop

major depressive disorder. The data on high

prevalence of these disorders and the information on the most vulnerable groups point to the

need for counselors to consider in treatment

planning that the observed behavior of depression, anxiety, and elation may likely be associated with a mental disorder.

Substance Use Among People

With Mood or Anxiety

Disorders

People with co­occurring mood or anxiety disorders and a substance use disorder probably

have used many substances. Though those with

depression may favor stimulation while those

with anxieties may favor sedation, considerable

overlap is apparent. The use of alcohol, perhaps because of its availability and legality, is

ubiquitous.

Specific Mental Disorders: Additional Guidance for the Counselor 375
The notion that substance use disorders are

caused, in whole or part, by an individual’s

attempts to “self­medicate” specific symptoms

with alcohol or illicit drugs has been a source of

debate. Many prominent researchers and clinicians have concluded that substance use is a

cause rather than an attempt to cure symptoms. Vaillant, for example, noted that

“depression is a symptom caused by alcoholism

more often than the reverse” (Vaillant 1995, p.

80). Both Brower and colleagues (2001) and

Raimo (1998) point out that insomnia, depression, and other “psychiatric” symptoms often

are more likely substance­use related, thus selfmedication in this case becomes using alcohol

(or other drugs) to block acute or protracted

substance withdrawal symptoms.

The “self­medication hypothesis” first proposed by Khantzian (1997) did not focus on

withdrawal symptoms, but proposed that those

who abuse drugs do so to deal with core psychopathology that might range from anger to

mania. While an attractive theory, research

does not entirely support this hypothesis. For

example, adolescents with attention deficit disorder should likely prefer to abuse stimulants

such as cocaine or amphetamines; however,

marijuana is by far the most commonly abuse

drug in this population (Flory et al. 2003) and

it has been demonstrated to make

attention issues

worse. Likewise,

patients with bipolar

disorder in either

depressed or manic

states should correspondingly use stimulants or depressives, but

Strakowski and colleagues (1998), after

following such

patients for a year

after acute hospitalization, could find

no pattern to their

use, nor types of

substances used. In

addition, there have been negative studies on

schizophrenia (Scheller­Gilkey et al. 2003), and

the only symptom/diagnosis in which data

appear to support that core mental disorder

symptoms lead to substance use, and substance

use leads to decreased symptoms, is that of

social anxiety, as demonstrated by Thomas and

colleagues (Thomas et al. 2003), though even in

this case there have been negative studies (e.g.,

Ham and Hope 2003).

The consensus panel cautions that the term

“self­medication” should not be used, as it

equates drugs of abuse (which usually worsen

health) with true medications (which are

designed to improve health). Equating substances of abuse with medications can be taken

quite concretely by some patients, especially

those who are either psychotic or are looking

for a clever rationalization for their addictive

behavior. Thus, such patients might conclude,

“Well, I’ll use the doctor’s medications during

the week, but my ‘medications’ on the weekend

(didn’t the doctor say ‘self­medication with

alcohol?’).”

Clients with severe

and persistent

substance use and

mood disorders

should not be seen

as resistant,

manipulative, or	 

unmotivated.

Key Issues and Concerns

The key issues and concerns for the client with

mild­to­moderate mood and/or anxiety disorders center on making the client comfortable

with, or at least able to tolerate, the treatment

environment. Often, the specific type of disorder and its symptoms need to be examined in

light of treatment demands. How does the

client get to the meeting? Are there any aspects

of the treatment environment that duplicate or

remind a client of a prior trauma experience?

Can a client who wakes up 2 hours earlier than

normal, say 5:00 a.m., develop some non­maladaptive way of coping with the monotony that

can feed the client’s feelings of depression? Do

other clients make fun of the obsessive­compulsive rituals of a client? An insightful counselor

and a dedicated staff can go a long way in

assisting the anxious or depressed client.

The majority of clients receiving treatment for

combined mood or anxiety disorders and substance use disorders improve in response to

376 Specific Mental Disorders: Additional Guidance for the Counselor
treatment. When they don’t improve, a re­evaluation of the treatment plan is warranted. A

client receiving antidepressant medication who

is abstinent from substances but anhedonic

requires a careful evaluation and assessment to

identify resistant psychiatric conditions that

require treatment. Based on assessment, an

additional treatment service such as psychotherapy may be added. Indeed, psychotherapy has been shown to improve the efficacy of

substance abuse treatment and of mental

health services that involve antidepressant

medication.

When clients do not improve as expected, it is

not necessarily because of treatment failure or

client noncompliance. Clients may be compliant

and plans may be adequate, but disease processes remain resistant. Clients with severe and

persistent substance use and mood disorders

should not be seen as resistant, manipulative,

or unmotivated, but as extremely ill and in

need of intensive support.

Strategies, Tools, and

Techniques

Engagement

As observed in the section above on

“Differential Diagnosis,” a client who shows

severe and acute levels of anxiety and mood

disturbance may have another psychological

disorder, such as psychosis, PTSD, or a PD.

The client may also have a history of suicidality

or may be suicidal currently. When this is the

case, see the pertinent portions of the

“Differential Diagnosis” section and the

“Suicidality” section.

In general, counselors can engage clients with

mood or anxiety difficulties by gathering

enough information to empathize with the

clients’ experience and acknowledge the legitimacy of the client’s feelings. Worried clients

tend to know they are overly concerned compared to other people, and depressed clients

often feel that they should not be depressed.

Depressed clients may view depression as a

personal shortcoming and imagine that they are

bringing others down with them.

A model of engagement that can be instructive

is the sympathetic physician who has seen it all

before and is calm in the face of what she or he

knows others find upsetting. That is, a substance abuse treatment counselor can attend to

the symptoms and their effects on the client,

while remaining an observant distance from the

worry itself or the depressed mood. For example, the counselor could tell a client that he or

she recognizes how painful and nerve­racking it

is for the client to be so concerned about the

possible loss of employment, while avoiding getting into the details of either the worst possible

outcomes or the worries. Such a strategy can

help with engagement.

Cognitive–behavioral therapy might help a

client see how he or she has developed a way of

viewing mainly the worst possible outcomes of

events, or how he or she tends to emphasize the

most negative aspect of a situation. However,

the client’s ability to recognize these patterns of

behavior may be a long­term goal that can only

be accomplished through time and trust.

Trying too soon to address such entrenched

habits of perception is not likely to be an effective engagement strategy. “Start low, go slow” is

a cliché physicians use to describe beginning

with a small amount of a medication to gauge

side effects, then slowly increasing the medication to a therapeutically effective dose. A similar approach can help with the engagement

phase of working with clients who have mood

and anxiety concerns.

Screening and assessment

Medical assessment

Clients with mood/anxiety disorders, particularly older adults, may have life­threatening

medical conditions, including hypoglycemia

(insulin overdose), stroke, or infections. These

conditions, as well as withdrawal and toxic

drug reactions, always must be considered and

require a thorough physical examination and

laboratory assessment. Clinical staff should

make appropriate referrals for medical assessSpecific Mental Disorders: Additional Guidance for the Counselor 377
ment and treatment. Facilities that have no

medical component should train assessment

staff in triage and referral, especially as part of

the intake process.

Assessing mood and anxiety 

symptoms

During initial screening sessions, clients with

substance use disorders may overemphasize or

underemphasize their psychiatric symptoms.

For instance, clients who feel depressed during

the assessment may distort their past psychiatric experiences and unwittingly exaggerate

the intensity or frequency of past depressive

episodes. Some clients experience feelings of

guilt that are excessive and inappropriate.

Other clients do not accurately label their

depression and fail to remember that they have

experienced depression before. Since clients

frequently confuse depression with sadness and

other emotions, it is important to obtain collateral information from other people and from

documents such as medical and psychiatric

records. It is critical to continue the process of

evaluation past the period of drug withdrawal.

For anxiety and mood symptoms especially,

observation is an important component of

screening and assessment. Does the client seem

calm and relaxed or nervous and distraught?

Often, with training in screening or assessment,

the counselor will learn to recognize some of

the features that provide clues to a client’s

mental status, such as rate of speech, affective

tone, cooperativeness, and so on.

Assessment instruments

A differential diagnostic evaluation can include

the clinical application of the DSM­IV, perhaps

in the form of a structured clinical interview.

Some specific and general standardized assessment measures are available for anxiety and

mood disorders. The Beck Depression

Inventory­II (BDI­II) (and its predecessor) has

been used in a wide variety of settings for the

past 25 years, and a Beck Anxiety Inventory is

available; both have English and Spanish versions and are proprietary. Substance abuse

treatment agencies need to provide training in

the use of assessment instruments so that counseling staff can take full advantage of the information and can play the most effective roles

possible in assessment processes.

Discussion of the case study (p. 379): While

many clients are depressed and anxious at the

onset of treatment—and someone in Jim R.’s

position might well be expected to have these

symptoms—it is still important to consider the

possibility that the depression or anxiety might

be a co­occurring mental disorder. The counselor notes the indications of depression and

formally screens for depression using the BDIII. Upon review at the next session the counselor notes and evaluates the increase in

depression and refers the client to a psychiatrist when the symptoms persist and intensify.

The psychiatrist establishes the co­occurring

mental diagnosis and, with the counselor,

develops a treatment plan that involves medication, cognitive–behavioral mental health counseling and continued substance abuse treatment

and monitoring of medication. With this integrated treatment approach, based on a sound

observation, rapid referral, and accurate diagnosis, the client begins making good progress in

treatment.

Psychosocial assessment

A comprehensive psychosocial assessment,

including an evaluation of the client’s support

system, is an important aspect of the overall

assessment. Such information is essential for

understanding the full context of anxiety and

mood troubles. Effective treatment planning

for both disorders depends on understanding

the total life situation of the client.

Crisis stabilization

When a mood and anxiety disturbance is at

mild or moderate levels, crisis stabilization

should not be needed. Substance abuse counselors should use their clinical skills and be

responsive to signs of an impending serious crisis, such as a moderately depressed client who

has given away his or her belongings or who

has begun to talk about wills or contacting old

friends.

378 Specific Mental Disorders: Additional Guidance for the Counselor
In terms of anxiety disorders, an immediate

episode of panic (and to some degree a dissociative state) can represent a crisis. In some cases,

the counselor may have to make arrangements

for a client to get home. Two of the acute anxiety conditions most commonly encountered in

emergency room settings are panic attacks and

dissociative states that may resemble psychosis.

However, some anxious clients misinterpret

their symptoms of chronic anxiety as symptoms

of an acute anxiety episode. Their misinterpretation may predispose the therapist to make the

same misinterpretation.

Interventions for acute anxiety conditions

include calming reassurance, reality orientations, breathing management, and when needed, sedative medications such as benzodiazepines. These interventions are nearly identical to those used for the two most common substance­related anxiety emergencies: withdrawal

from sedative­hypnotics (including alcohol) and

Case Study: Assessment of Mood and Anxiety Disorders

Jim R. enters the substance abuse treatment center after detoxification at the hospital. He was admitted

fol­lowing a drinking and driving incident in which he hit the side of a building, fortunately injuring no

one. The counselor immediately sees that Jim R. is depressed and somewhat anxious. He talks about how

he has screwed up, will probably lose his license, and will then not be able to work. He says he has tried

repeatedly to stop drinking and cannot succeed; his life is hopeless.

Jim R. is not thinking of suicide, but he has lost a great deal of weight recently, has difficulty concentrating,

feels worthless, moves suddenly in an agitated way (he shifts his position in the chair continually), and

admits to difficulty sleeping. The counselor senses that the client may be depressed and notes the indications

of depression in the record. To obtain further collaboration, the counselor immediately uses the BDI­II and

finds that Jim R. scores 15. A score of 15 represents a moderate level of depression, but the treatment program’s protocol for the use of the BDI­II by counselors calls for weekly monitoring of moderately scoring

clients with repeat administrations of the BDI­II. In the next session, the counselor notes signs of increased

depression and reevaluates the symptoms. He finds that Jim R. now scores 40 on the BDI­II. According to

the established protocol, he now refers him to a psychiatrist, suggesting that Jim R. may be in need of medication and a differential diagnosis.

The psychiatrist does a longitudinal assessment in which she explores Jim R.’s drinking and establishes a

diagnosis of alcohol abuse disorder. The psychiatrist also explores when Jim remembers being depressed and

gauges the severity and persistence of these depressions. Finding a pattern of persistent depression with anxious features, such as excessive worry, that precedes Jim R.’s drinking, she prescribes an antidepressant

with a calming effect. She tells Jim R. the pills should help him feel less worried and sleep better even though

the pills are neither tranquilizers nor sleeping pills, and she stresses the importance of taking them regularly.

Noting that Jim R. is a college graduate, she prescribes a workbook on depression (David Burns, The

Feeling Good Handbook) to help him learn about the disease. The psychiatrist informs the substance abuse

treatment counselor of her action and asks the counselor to continue monitoring the client’s depression. She

also refers Jim R. for cognitive–behavioral sessions with a mental health clinician to help him overcome his

negative thinking and regain his sense of worth.

On Jim R.’s next visit, the substance abuse treatment counselor checks Jim R.’s pill box and finds that many

of the pills have not been taken. He uses motivational therapy techniques to encourage Jim R. to take the

pills regularly. He also reinforces the work of the mental health counselor, pointing out that the “stinking

thinking” discussed in AA as a bad rationale for drinking is similar to the thought patterns that drive his

depression. Gradually, Jim R. is able to manage his disorder through medication and improved thought patterns.

Specific Mental Disorders: Additional Guidance for the Counselor 379
intoxication from stimulants (including

cocaine). While the use of benzodiazepines generally is not problematic during acute withdrawal, their use may become a problem for

abstinent, recovering people. Such people may

have abused benzodiazepines before they

became abstinent, and the use of benzodiazepines to calm the anxiety disorder may lead

to relapse of the addictive behavior.

Interventions for acute anxiety conditions

should include behavioral, cognitive, and

relaxation therapies, often in combination with

long­term serotonergic and depressant medications.

During an acute panic attack, people often

believe that they are having a heart attack, feel

dizzy, and are unable to catch their breath.

Enforced regular breathing through the use of

a paper bag helps to regulate breathing and

diminish excess release of carbon dioxide. Such

breathing exercises, education about symptoms, and reassurance will diminish panic

symptoms for many clients. These clients also

should be examined by a medical professional

such as a nurse to identify any person who may

be having an actual heart attack.

Short­term care and 

treatment
 

The acronym MASST, defined in the text box

below, is a reminder for counselors of the areas

of substance abuse recovery that need to be

continually assessed.

MASST Areas of Recovery

for Assessment

M: Meetings (12­Step or other recoveryoriented self­help)

A: Abstinence goals

S: Sponsor and other helping people

S: Social support systems

T: Treatment efforts

In terms of mood and anxiety problems,

MASST can be used to incorporate specific

strategies within the client’s overall recovery

efforts. Though there are many interventions

for anxiety and mood disorders other than

medications, medications often are a significant

part of such treatment efforts. For clients with

more than mild levels of disturbance, medications can be essential.

For many clients in early recovery from substance abuse, treatment of anxiety disorders

can be postponed unless a certain or verifiable

history shows that the anxiety preceded the

addiction or is incapacitating. If symptoms are

mild and do not interfere with functioning,

including participation in treatment, it is judicious to wait to see if the symptoms resolve as

the substance abuse treatment progresses.

Antecedent traumas, as well as dysfunctional

family situations that have been identified during the assessments, should be addressed in a

supportive and calming manner. However,

affect­liberating therapies probably should be

deferred until the client is stable with respect to

substance abuse and acute anxiety has been

established. Issues of importance to the client

and raised by the client should not be ignored,

but exploration of underlying trauma should

not be encouraged until the client is stabilized.

Supportive, cognitive, behavioral, and dynamic

therapies all can be used, but in early recovery,

clients need significant support and will have

limited tolerance for anxiety and depression.

The emphasis should be on supporting recovery, attending 12­Step meetings, and participating in other self­help and group therapies.

Insight­oriented treatments must be measured

carefully and limited early on by their potential

to increase anxiety and trigger relapse. When

psychotherapy is immediately essential, clients

should be referred to recovery­oriented psychotherapists who will integrate psychotherapy

with mutual self­help approaches.

Clients may overuse medications or relapse to

illicit drugs. Certain medications that do not

produce physical dependence or withdrawal

and have much lower potential for abuse have

380 Specific Mental Disorders: Additional Guidance for the Counselor
been found to be effective for treating anxiety

disorders. Many are as effective as the benzodiazepines but without the abuse liability. The

antidepressants fluoxetine (Prozac) and sertraline (Zoloft) and the antianxiety medication

buspirone (BuSpar) are medications that can

be used to treat symptoms of anxiety disorders,

have good safety profiles, are not euphorigenic

(producing euphoria), and have few drug interaction cautions. They can be used in the management of subacute withdrawal states. When

these drugs do not produce the desired results,

the tricyclic and monoamine oxidase inhibitor

antidepressants may be used. (See appendix F

for a discussion of psychiatric medications.)

Medications should be used in combination

with nondrug treatment approaches. Although

studies are still underway, acupuncture, aerobic exercise, stress reduction techniques, and

visualization techniques may be useful components of treatment and recovery. These tools

can be valuable adjuncts for the reduction of

stress. Clients should be taught that efforts to

improve their general health, such as eating

more healthful foods and exercising regularly,

can lead to better mental health.

It is beyond the scope of this TIP to provide

comprehensive review on the use of psychotherapeutic treatment. However, there are

numerous resources regarding counseling and

psychotherapy for depression and anxiety

(e.g., Barlow 2002).

Longer term care

Always foremost in longer term COD treatment

are the issues of diagnosis and re­diagnosis.

Once a patient has engaged in treatment and

has been abstinent for over a month, most of

the substance­induced depression/anxiety

symptoms caused by either the substance or its

withdrawal should have abated. This allows for

the diagnosis of ongoing symptoms to be more

certain. It should be recognized that just

because psychiatric symptoms abate with abstinence and addiction treatment alone doesn’t

mean that such symptoms may not re­occur

later and need specific mental health services,

such as medications. It does, however, make

this much less likely. If a patient is diagnosed

with COD, is in active addiction treatment, but

has been started on a psychiatric medication

for depression, anxiety, or both by an outside

prescriber (either a psychiatrist or primary

care physician), then the substance abuse

counselor should refer to chapter 5 of this TIP

(the section titled “Monitor Psychiatric

Symptoms”) to identify strategies for monitoring symptoms and supporting medications.

While medications are useful for anxiety disorders, they are not a substitute for substance

abuse treatment or other activities related to

recovery. Cognitive and behavioral techniques

used in substance abuse treatment often are as

effective as medications in treatment of anxiety

disorders, though they generally take longer to

achieve an equivalent response for the mental

illness component of the disorder.

It should also be noted that certain depressions

may become so severe that they can cause

symptoms of mental disorders, such as delusions (e.g., “I’m so evil that I was responsible

for starting World War II”) or hallucinations

(e.g., “When I’m alone I hear my name being

called and the voices tell me that I am bad”).

These types of depression need immediate psychiatric consultation and medication treatment.

Patients who are significantly anxious or

depressed should always be evaluated for suicide: Counselors are referred to chapter 5, the

subsection “Potential for harm to self or others” within the section titled “Monitor

Psychiatric Symptoms,” as well as to the suicidality sections in chapter 8 and this appendix,

for details on evaluation and management.

The consumption of foods containing stimulants should not be overlooked. People who

consume significant amounts of caffeine and

sugar may have a higher risk for episodes of

anxiety and depressive symptoms. Chocolate,

large quantities of refined carbohydrates, and

any diets that cause significant variations in

blood sugar levels should be avoided, since this

condition will tend to aggravate or induce both

mood and anxiety states. It is important to be

Specific Mental Disorders: Additional Guidance for the Counselor 381
sure that eating habits do not imitate the rushes

and crashes of substance abuse.

Use of 12­Step and other mutual

self­help programs

Participation in 12­Step programs provides

valuable therapeutic experiences for many

recovering people who have mood or anxiety

disorders. People who have a social phobia and

the fear of public speaking often are extremely

resistant to attending self­help meetings. Yet,

such people can make tremendous recovery

gains in terms of anxiety desensitization and

substance abuse recovery.

Few situations are as safe, supportive, predictable, and undemanding as the average 12­

Step group meeting. For this reason, groups

such as AA and Narcotics Anonymous (NA)

provide constructive opportunities to help

clients desensitize social fears. However, anxious clients must not simply be thrust unprepared into 12­Step group meetings. Counselors

should educate and prepare such clients

regarding the process and approach of 12­Step

and other self­help group meetings.

A stepwise approach to using

mutual self­help

It is important for substance abuse treatment

staff to appreciate the difficulty and distress

that are experienced by people who have social

phobias and fears of speaking in public. Staff

who assist such clients with 12­Step group participation should become knowledgeable about

the signs and symptoms, course, and treatment

of generalized anxiety disorder, panic disorder,

and the phobias, especially social phobia and

other anxieties related to public speaking and

social situations.

Staff can help socially anxious clients participate in 12­Step group meetings by using a stepwise approach of progressively active exposure

and participation based somewhat on the principles of systematic desensitization:

• One of the least intense levels of preparation

involves the use of mock AA/NA meetings

consisting of staff and clients. This process

makes it possible to stop the meeting frequently, discuss various meeting components,

examine group methods, and allow potential

participants to observe and practice.

• The next level of intensity involves attending

a 12­Step group meeting as a nonspeaking

observer. Staff should help clients to understand that being a nonspeaking observer is a

transitional phase and is not a substitute for

active participation. For this reason, it may

be helpful to limit nonspeaking observation

by the client to a specific number of meetings. At first clients can attend meetings with

someone they know and trust, and they can

stay in the back of the meeting room close to

an exit door.

• The next level of intensity involves clients

attending a limited number of 12­Step meetings during which they identify themselves

but do not talk about themselves. The counselor can give assistance by providing easily

rehearsable suggestions for self­introductions

such as, “Hi, my name is Mary. I’m an alcoholic and I am glad to be here, although I am

a little nervous.”

Since the mutual support associated with the

12­Step group meetings can occur outside of

the meeting, anxious clients should be encouraged to do more than merely attend and participate in the meetings. Rather, they should

arrive before the meeting begins and should

linger and mingle with others following the

meeting. Clients can be encouraged to volunteer to help set up the room, make the coffee,

or clean up afterward. In particular, socially

phobic clients can be encouraged to join others

for coffee and conversation after the meetings

on a more one­to­one basis, a traditional aspect

of 12­Step group involvement.

By participating in step­by­step, rehearsed

activities, many anxious and depressed clients

seem to break through an internal barrier. As

they do, participation in self­help group meetings becomes an integral aspect of recovery

from substance use disorders and mental

health problems.

382 Specific Mental Disorders: Additional Guidance for the Counselor
Case Study: Phobia, Tranquilizers, and Alcohol

Lan S. has been referred to the substance abuse treatment clinic by her physician because of abuse of prescribed tranquilizing drugs and alcohol. The counselor finds Lan S. somewhat nervous but apparently in

stable condition and willing to discuss her substance abuse problems. During the course of conversation, she

mentions her discomfort in restaurants and malls. When the counselor refers her to a 12­Step group, Lan S.

seems hesitant and uncomfortable. The counselor identifies her symptoms as resistance to treatment and

strongly emphasizes the importance of attendance if she wants to change.

In future sessions, however, the counselor finds her refusal to go to group remains steadfast. After conferring with a mental health counselor, she probes Lan S.’s discomfort about going to group and explores the

possibility of other similar problems. She finds that Lan S. orders all her clothes online to avoid going to

stores and that she rarely appears in public. Coming to the counseling session is an ordeal made possible

only by the fact that her mother takes her to the clinic and waits for her in the counseling center.

The counselor refers Lan S. to the psychiatrist, who finds that Lan S. has a social phobia. He prescribes

Zoloft, a selective serotonin reuptake inhibitor (SSRI) antidepressant, and arranges for a course of treatment with a mental health counselor who specializes in phobias. He asks the substance abuse treatment

counselor to coordinate closely with the mental health counselor to develop a strategy to enable Lan S. to

attend meetings. Together, they work out a phased approach to regular attendance at meetings in which she

first attends a meeting at the clinic, then is escorted to a meeting at another part of town. The counselors

also provide psychoeducation for both Lan S. and her mother to help them understand her mental disorder.

The substance abuse treatment counselor works with Lan S.’s sponsor to ensure understanding of her limitations. Gradually, Lan S. is able to attend AA regularly on her own.

Discussion: Counselors should be aware that some “resistance” may actually indicate a mental disorder.

Until the disorder is treated, this obstacle will remain in the client’s path and deter recovery. At the same

time, some clients with social phobia or other anxiety disorders may choose not to attend 12­Step groups;

this is a legitimate choice. Such clients should be offered alternatives, such as increased amounts of individual therapy. As long as they can engage in such treatment alternatives, it is important not to convey to clients

that they are “wrong” or “bad” or “not doing recovery right” by choosing not to attend 12­Step groups.

The stepwise approach described for clients

with anxiety disorders can be adapted for

clients who are depressed. Anxious clients often

avoid group participation and public speaking,

saying to themselves, “If I talk or if I am

noticed, I will freak out.” Similarly, depressed

clients often avoid group participation and

other recovery activities, perhaps thinking, “I

just don’t have the energy to go. Why bother?”

The counselor must elicit comments, understand them, and help clients to reverse these

internal barriers to recovery and participation

in group and other social activities.

Specific Mental Disorders: Additional Guidance for the Counselor 383
Case Study: OCD and Alcohol

Marla W. is a 40­year­old woman with a secret: She has been compulsively washing her hands for many

years, and cannot stop. She began drinking to try to relax, but found herself gradually drinking more and

more in an attempt to cope with what she knew was very unhealthy behavior. She feels triggered to wash her

hands whenever she thinks of “germs,” and feels that she cannot get them clean enough. She sometimes

washes up to 100 times a day, and has constricted her life so others will not see her. When she drinks, she is

alone.

The substance abuse treatment counselor discovers Marla W.’s obsession when she notices Marla W.’s

repeated trips to the rest room. She discusses Marla W.’s symptoms and assures her that some medication

and therapies may be able to help her overcome the disorder. She refers Marla W. to the psychiatrist for

assistance.

Discussion: Substance abuse treatment counselors often consider compulsive behaviors (gambling, shopping,

overeating, sex, work, etc.) to be addictions. However, they should also consider that some compulsive

behaviors may be part of an OCD and clients may benefit by having further evaluation and the knowledge

that specific medication and therapies are available to assist them.

Case Study: GAD and Protracted Withdrawal

Ray Y., a 50­year­old husband and father of teenagers, is going through protracted alcohol withdrawal. He

appears “edgy” and irritable, sometimes sad, and complains to his substance abuse treatment counselor of

insomnia, headaches, and an upset stomach. He tells the counselor he can barely stand not to drink: “I’m

jumping out of my skin.” Although these symptoms are common during protracted withdrawal, because they

have persisted for over a month, the counselor begins a more detailed exploration.

The counselor asks Ray Y. whether he had these symptoms before he used alcohol and Ray Y. says he’s

“always been this way.” He worries about everything, even events that are weeks away. His family vacations

are nightmares because every aspect of vacation planning troubles him and keeps him awake. During family

therapy, it becomes apparent that his daughter deeply resents his controlling and distrustful behavior, as

well as his overprotective stance toward all her social commitments. The counselor refers Ray Y. to the psychiatrist, who diagnoses generalized anxiety disorder and begins a course of medication and initiates mental

health counseling. The family receives help coping with Ray Y.’s disorder and the daughter is referred for

short­term counseling to help her address the mental problems she is beginning to develop as a result of her

father’s excessive control.

Discussion: Even though anxiety symptoms are quite common during protracted withdrawal, counselors are

advised to consider the possibility that an anxiety disorder is sometimes indicated. Symptoms should be

tracked to see whether they persist beyond the normal time that might be expected for protracted withdrawal (about a month). Counselors should also be aware of the effect of such disorders on close family members.

Children and adolescents may not understand that a parent has a mental disorder and may be relieved to

have a way of understanding and coping with difficult behavior.

384 Specific Mental Disorders: Additional Guidance for the Counselor
Schizophrenia and

Other Psychotic

Disorders

Description

Psychosis is the term for a severely incapacitated mental and emotional state involving a person’s thinking, perception, and emotional control. Psychosis refers to distorted thoughts in

which an individual has false beliefs, sensations

or perceptions that are imagined, and/or very

extreme and unusual emotional states along

with deterioration in thinking, judgment, selfcontrol, or understanding. In everyday terms,

people who are acutely psychotic cannot tell

the difference between what is real and what is

not, but this common distinction is too simplistic to be clinically useful. Psychosis usually is

expressed clinically as a combination of one or

more of the following symptoms:

• Belief in delusions (such as that one is being

followed by people from Mars, or that one is

a very important person whom the President

wants to talk to right away, or that one is

eternally damned).

• Hearing or seeing things that are not there

(hallucinations) and being unable to recognize that what is being experienced is not

real, such as hearing voices that say self­condemning or other disturbing things, or seeing

a mocking or threatening face of the Devil.

• Severe emotional excitement, which can manifest as a “manic” state with feelings of exuberance, invincibility, grandiosity. Often this

state is accompanied by poor judgment and

prolonged functioning with little sleep, as is

seen in people with bipolar disorder during

the manic phase. Alternatively, an emotional

state reflecting psychosis may manifest as

severe agitation, sometimes with vaguely

expressed worries or fears and/or with tears

and depressive consternation.

• On rare occasions, a very different type of

psychotic reaction can occur, one that manifests as immobility, stupor, or rigid body

position over extended periods of time. This

is known as catalepsy, one of several forms of

catatonic states that occur during certain

types of schizophrenic episodes.

Although schizophrenia is the illness most

strongly associated with psychotic disorders,

people with bipolar disorder (or what used to

be termed “manic­depressive illness”) may

experience psychotic states during periods of

mania—the heightened state of excitement, little or no sleep, and poor judgment described

above. Other conditions also can be accompanied by a psychotic state, including toxic poisoning, other metabolic difficulties (infections

[e.g., late­stage AIDS]), and other mental disorders (major depression, dementia, alcohol

withdrawal states, brief reactive psychoses,

and others).

For the purpose of this TIP, the focus will be

on schizophrenia and bipolar disorder.

Although schizophrenia is a “thought” disorder

and bipolar disorder is a “mood” or “affective”

disorder, these often are the diagnoses that

States and/or other funding agencies use to

establish special programs for people with

“severe and persistent mental illness” or the

“severely mentally ill.” In practice, however,

eligibility for such programs often is more

largely determined by the mental health problems and their impact on the basics of the

client’s life—living arrangements, employment,

hospitalizations, ability to care for self—than

by the client’s specific diagnosis.

Substance abuse treatment counselors typically

do not see clients in the throes of an acute psychotic episode, as such psychotic patients more

likely present, or are referred to, ERs and

mental health treatment facilities. Counselors

are more likely to encounter such clients in a

“residual” or later and less active phase of the

illness, the time at which these individuals may

receive treatment for their substance use disorders in an addiction treatment agency. Even if

the substance abuse treatment counselor never

sees a client during an actively psychotic period, knowing what the client experiences as a

psychotic episode will enable the counselor to

understand and assist the client more effectiveSpecific Mental Disorders: Additional Guidance for the Counselor 385
ly. On the other hand, counselors are increasingly treating clients with methamphetamine

dependence who often have residual paranoid

and psychotic symptoms, and may need

antipsychotic medications. These clients may

continue with such psychotic symptoms for

months, or even years (Chen et al. 2003).

Schizophrenia

Schizophrenia is best understood as a group of

disorders that can be divided into subtypes: (1)

paranoid type, in which delusions or hallucinations predominate; (2) disorganized type, in

which speech and behavior peculiarities predominate; (3) catatonic type, in which catalepsy or stupor, extreme agitation, extreme negativism or mutism, peculiarities of voluntary

movement or stereotyped movements predominate; (4) undifferentiated type, in which no single clinical presentation predominates; and (5)

residual type, in which prominent psychotic

symptoms no longer predominate.

Symptoms of schizophrenia include delusions,

hallucinations, disorganized speech (e.g., frequent derailment or incoherence), grossly disorganized or catatonic behavior, and deficits in

certain areas of functioning—for example, the

inability to initiate and persist in goal­directed

activities. These symptoms regularly develop

before the first episode of a schizophrenic

breakdown, sometimes stretching back years

and often intensifying prior to reactivations of

an active, acutely psychotic state.

Relatively subtle indicators may exist. For

example, a clinician may notice a client’s tendency toward loose associations, a symptom

that is exhibited when ideas expressed appear

to be disconnected or only very loosely connected. A similar disturbance, called tangentiality or tangential thinking, occurs when a

client gets lost in telling a story and cannot get

to the point. As with many of the behaviors discussed, isolated occurrences of these phenomena are unremarkable, but their repetition can

be a cause for concern.

Clinicians generally divide the symptoms of

schizophrenia into two types: positive and negative symptoms. Acute course schizophrenia is

characterized by positive symptoms, such as

hallucinations, delusions, excitement, and disorganized speech; motor manifestations such as

agitated behavior or catatonia; relatively minor

thought disturbances; and a positive response

to neuroleptic medication. Chronic course

schizophrenia is characterized by negative

symptoms, such as lack of any enjoyments

(“anhedonia”), apathy, very little emotional

expressiveness (“flat affect”), and social isolation. Some clients will live their entire lives

exhibiting only a single psychotic episode; others may have repeated episodes separated by

varying durations of time.

Brief reactive psychosis describes a condition

in which an individual develops psychotic

symptoms after being confronted by overwhelming stress.

Bipolar disorder

Bipolar disorder, formerly termed “manicdepressive illness,” is meant to characterize the

fluctuations in mood from one end or “pole” to

the other—severe depression to mania. Unlike

schizophrenia, bipolar illness might have little

effect on the client’s ability to think; that is, it

does not necessarily include the symptoms of a

“thought disorder,” whereas schizophrenia at

some point always shows disturbances of

thought (such as delusions, bizarre beliefs, or

loose associations).

Depressive phases in bipolar clients are similar

to those in clients who are severely depressed—

that is, the person feels sad; might feel life is

not worthwhile; gets little or no enjoyment

from anything, even from involvement with

children or family/friends; and has altered

appetite and sleep needs, for example, waking

up early in the morning almost 2 hours before

normal or oversleeping. Similarly, the client

may overeat or have little or no appetite. The

person might experience lethargy; fatigue easily; have feelings of guilt or worthlessness (sometimes for seemingly trivial things) or show

386 Specific Mental Disorders: Additional Guidance for the Counselor
strong feelings disproportional to the acts or

thoughts involved; and experience recurrent

thoughts of death, illness, or manifest suicidal

thoughts, plans, or attempts.

Manic episodes for someone with bipolar disorder also vary in intensity. Full­blown, intense

mania (during which a client might, for example, take off all his or her clothes and run to a

church to declare that the secrets of the universe have been revealed) is relatively rare

and, especially with medication, usually shortlived. An evolving manic episode might be hard

to detect, especially in someone who is drinking

and/or using drugs; some people with mania

can get by on a day­to­day basis, partying and

barely sleeping, telling tall tales others might

ignore, and even being intact enough to persuade others that their delusion of vast wealth

is true. People in a manic state have been

known to get yachts to take to sea for a trial

run or to run up thousands in bills at expensive

hotels before anyone recognizes that the individual has not changed clothes in 6 days and

cannot carry on a conversation without stating

outlandish impossibilities (such as owning

Nebraska or being married to the queen of

England).

In between the extremes of elation and depression, some clients with bipolar disorder are

likely to struggle almost all the time with mildto­moderate depression and, on occasion, with

“hypomanic” (mildly elevated) states that can

carry deterioration in judgment, leading to

legal trouble, financial loss, or relapse to abusing substances. For the 20 to 30 percent of people with bipolar illness who are not fully functional between episodes of mania and/or

depression, the residual phase is usually characterized by mood instability, interpersonal

problems, and/or occupational difficulties

(APA 2000). However, clients with bipolar disorder who are successfully treated frequently

return to positive and productive lives without

any future disruption.

Schizophrenia is

a “thought”

disorder and

bipolar disorder is

a “mood”

or “affective”

disorder.

Differential Diagnosis

Psychosis versus substanceinduced psychotic disorder

Differential diagnosis among psychotic disorders can be challenging, even for experienced

clinicians and diagnosticians, especially when

drugs and alcohol are involved. When a client

presents in a psychotic state, any immediate or

recent substance use is difficult to determine,

and it may be impossible to discern whether the

hallucinations or delusions are caused by alcohol or other drug use. If the hallucinations or

delusions can be attributed to substance use,

but are prominent and beyond what one might

expect from intoxication alone, the episode

would be described as a “substance­induced

psychotic disorder.” Hallucinations that the

person knows are solely the result of substance

use are not considered indicative of a psychotic

episode; instead, they are considered part of

what DSM­IV­TR calls Substance Intoxication.

Psychedelic, hallucinogenic, and stimulant

drugs can produce reactions with psychotic features, especially in clients with co­occurring

schizophrenia and bipolar disorders. People

who use phencyclidine

(PCP) and who experience one psychotic

episode are “more

likely to develop

another with repeated

use” (Goldsmith and

Ries 1998, p. 971). In

addition, withdrawal

from some substances, especially

alcohol, can produce

states that can mimic

psychosis. Consider

the following descriptions by Goldsmith

and Ries (1998, p.

970) of the known

concomitants of withdrawal:

Specific Mental Disorders: Additional Guidance for the Counselor 387
• Sedatives: “A protracted withdrawal syndrome has been reported to include anxiety,

depression, paresthesias [a tingling, prickling, or burning sensation on the skin], perceptual distortions ... headache, derealization and depersonalization, and impaired

concentration.”

• Amphetamines: Many people who abuse stimulants report a state of hopelessness, discomfort, and unhappiness that includes little or

no pleasure. This state may persist for weeks.

“Some stimulant addicts report hallucinatory

symptoms that are visual (e.g., coke snow)

and tactile (e.g., coke bugs). Sleep disturbances are prominent in the intoxicated and

withdrawal states, as is sexual dysfunction.”

• Opioids: “There are reports of an atypical

opiate withdrawal syndrome consisting of

delirium following the abrupt discontinuation

of methadone.”

• Alcohol: “A few chronic heavy drinkers experience hallucinations, delusions, and anxiety

during acute withdrawal, and some have

grand mal seizures. Brain damage of several

types is associated with alcohol­induced

dementias and deliriums.”

Some clinicians have developed clues to differentially discriminate one type of disorder from

another. For example, DSM­IV (APA 2000, p.

300) advises that “certain types of auditory hallucinations (i.e., two or more voices conversing

with one another or voices maintaining a running commentary on the person’s thoughts or

behavior) have been considered to be particularly characteristic of schizophrenia....”

Mendoza and Miller (1992) suggest that people

who abuse cocaine and become paranoid maintain their abstract thinking and basic clear

thinking; they have delusions that are poorly

developed and of a non­bizarre nature

(Goldsmith and Ries 1998). Fortunately, both

the substance abuse treatment clinician and the

physician responsible for the management of a

client with psychotic­like symptoms can attend

directly to the symptoms presented and begin

by treating those symptoms without requiring

an exact diagnosis beforehand.

Physical illnesses and 

reactions to medication

Any number of physical illnesses or medication

reactions, from brain tumors to steroid side

effects, can cause a psychotic episode or psychotic behavior. These are situations when the

thorough diagnostician, one who follows a

client until the details of the disorder and the

correct differential diagnosis are clear, earns

his or her keep.

Schizophrenia versus bipolar

disorder

Detailed and complex strategies for conducting

a differential diagnosis take into consideration

the typical “natural” histories of both substance use disorders and schizophrenia or

bipolar disorder and the pattern of presenting

symptoms (see, e.g., Rosenthal and Miner

1997). Often, continued input from the substance abuse counselor and treatment team

staff will help clarify the diagnosis or lead a

psychiatrist to change a diagnosis from

schizophrenia to bipolar disorder. This may

also lead the psychiatrist to switch a client’s

medication from one of the “antipsychotic”

medications to a “mood stabilizer” such as

lithium.

Collateral information can be important in

making an accurate diagnosis. For example,

Sloan and colleagues (2000) found that a selfreport of having been hospitalized with a diagnosis of bipolar disorder and/or a report of a

prior positive therapeutic response to a mood

stabilizer were better measures of bipolar disorder than questions about symptoms. Some

types of delusions brought on by drinking

(often delusions of jealousy) or by methamphetamine use can be recognized easily with

input from collateral sources that clarify the

situation. Without such information, staff can

be misled into believing the delusion is true.

388 Specific Mental Disorders: Additional Guidance for the Counselor
Prevalence

Schizophrenia

The lifetime prevalence rate for adults with

schizophrenia is between 0.5 and 1.5 percent

(APA 2000). The Epidemiologic Catchment

Area (ECA) studies reported that among clients

with schizophrenia, 47 percent met criteria for

some form of a substance use disorder (Regier

et al. 1990). Fifteen years earlier, McLellan and

Druley (1977) also found that about half of

male inpatients with schizophrenia could be

expected to have a co­occurring addiction to

amphetamines, alcohol, or hallucinogens.

Research by Fowler et al. (1998) reviewed

prior studies and assessed 194 Australian outpatients with schizophrenia, finding similar

results with more than 59 percent of the group

having lifetime alcohol abuse/dependence. In

an almost all­male study of the medical records

of 1,027 veterans treated for some form of

schizophrenia, Bailey and colleagues (1997)

found that 50.8 percent of the clients had

received a diagnosis of a substance use disorder.

Bipolar disorder

The lifetime prevalence of bipolar disorder also

is roughly 1 percent of the general U.S. population (APA 2000), so both schizophrenia and

bipolar disorder are relatively rare compared

to major depressive illness, which has lifetime

incidences in the general population of 10 to 25

percent for women and 5 to 12 percent for men

(APA 2000). People with bipolar disorder also

are subject to high rates of co­occurring substance abuse and dependence, with even higher

rates in specific populations. In the ECA study,

nearly 90 percent of those with bipolar disorder in a prison population had a co­occurring

substance use disorder (Regier et al. 1990).

Family members

and community

supports, when

appropriate,

should be included

in a client’s overall

treatment process.

Substance Use Among People

With Bipolar Disorder or

Schizophrenia

The search for specific patterns of use among

clients with schizophrenia or bipolar disorder

has not led to any clear pattern of drug choice.

Instead, there appears a strong likelihood that

whatever substances happen to be available

will be the substances used most typically

(Galanter et al. 1988). In research on the substance use of Australian and American patients

with schizophrenia, Fowler and coworkers

(1998) attributed the “slightly different pattern

of substances abused (i.e., absence of cocaine)”

to the “relative differences in the availability

[of] certain drugs” (p. 443).

There is evidence of increasing use of alcohol

and drugs among persons with schizophrenia.

Fowler and colleagues reviewed studies on the

substance use of people with schizophrenia,

concluding that alcohol abuse and dependence

increased “from 14 to 22 percent in the 1960s

and 1970s ... to 25 to 50 percent in the 1990s”

(1998, p. 444). The same analysis showed that

stimulant abuse or dependence also may have

nearly doubled from the 1970s to the 1990s,

from about 13 percent to between 17 percent

and 31 percent, respectively. However, Fowler

and coworkers also

found that hallucinogen abuse or dependence declined from

roughly 12.5 percent

in the 1970s to 7 percent in the 1990s, and

they estimate that

cannabis use has

remained stable at an

estimated range of

12.5 to 35.8 percent.

Sonne and Brady

(1999, p. 611) report

that some individuals

with bipolar disorder

use cocaine to “intensify and lengthen

euphoric mood states

Specific Mental Disorders: Additional Guidance for the Counselor 389
rather than to self­medicate depressive

episodes.” However, other clinicians see the use

of alcohol by people with manic behaviors as

their way of trying to sedate the heightened

emotional state. Many authors report that

clients will claim to use substances to counteract feelings of hopelessness or other symptoms

of illness, but a majority of clients report that

they use drugs or alcohol in a manner similar

to persons who are not mentally ill—that is, to

“get high” and/or to be sociable and fit in with

others. It seems likely that clients can be confused about their substance use. Addington and

Duchak (1997) report that clients state they use

substances to feel less depressed—even though

65 percent of them indicated that alcohol

increased their symptoms of depression.

Key Issues and Concerns

Suicide and suicidal behaviors are major, ongoing concerns for this client population, and the

substance abuse counselor should have a thorough understanding of her or his role in preventing suicide. Medication compliance should

be emphasized strongly and monitored at every

session. The cyclical nature of bipolar disorder,

frequently punctuated by bouts of deliberate

medication noncompliance, can test a counselor’s patience, and it is crucial to cultivate

and convey an understanding of the allure of

the manic episode.

Individuals with bipolar disorder do not have

the same cognitive limitations as individuals

with schizophrenia. Therefore, people with

bipolar disorder can function at a high level in

the work environment, and the maintenance of

their work position can be a key factor in their

long­term, successful treatment. Consequently,

quick attention to signs of depression or mania

can be critical, especially as medication might

be able to ward off the worsening of the client’s

condition. For developing mania, which is virtually nonresponsive to psychosocial interventions, a variety of mood stabilizers have

demonstrated remarkable efficacy. Their timely use can avert potentially life­altering, negative events.

Family members and community supports,

when appropriate, should be considered for

inclusion in the overall treatment process for

these clients. The psychoeducational component of treatment should include both mental

health and substance use disorder information,

from causes and the natural histories of the disorders to the recovery process and how the illnesses can interact.

A recovery perspective and a compassionate

attitude toward clients can convey hope and

allow them to envision significant recovery and

improvement in their lives. For example, in a

focus group study of 18 clients with schizophrenia and a substance use disorder, 16 had

received a course of individual therapy, and all

cited contact with their individual therapist as

“...helpful in their efforts to change substance

abuse patterns.” Many of the focus group participants stressed the importance of the humanto­human nature of their relationship with the

therapist and the key role of family members

and friends (Maisto et al. 1999, p. 223).

Strategies, Tools, and

Techniques

Engagement

For clients with psychosis, as for others with

co­occurring disorders, it is essential to build a

relationship. Actively helping them to secure

basic needs such as medical assistance and

housing helps with the engagement process, and

also helps create the level of stability needed

for treatment to proceed successfully (see

Figure D­11). It also is helpful to increase client

motivation for treatment through involvement

of the client’s family.

Screening and assessment

Clinicians experience a common difficulty in

determining whether psychotic symptoms represent a primary mental disorder or are secondary to substance use. In the early phase of

assessment, the goal is to stabilize the crisis

rather than to establish a diagnosis, which is

390 Specific Mental Disorders: Additional Guidance for the Counselor
often best determined during a multiple­contact, longitudinal assessment process. The best

assessments include direct client interviews,

collateral data, observations of the client, and

a review of available documented history.

Especially with clients who have bipolar or

schizophrenic disorders, the counselor will

profit from always actively inquiring how they

are feeling and how things have been going.

These clients might sometimes inexplicably fail

to describe the most significant events or

changes spontaneously, even though they are

forthright and open about such matters when

asked.

Assessment of high­risk conditions

The initial step of every assessment is to determine whether the individual has an imminent

life­threatening condition. Three domains of

high risk require assessment: biological (or

medical), psychological, and social. At any

given time, one aspect of this biopsychosocial

approach may be more urgent than the others.

Medical risks

The goal of medical or biological assessment is

to ensure that clients do not have life­threatening disorders such as substance­induced toxic

states or withdrawal, delirium tremens, or

delirium.

Clients may exhibit symptoms that represent an

exacerbation of their underlying chronic mental illness. Their symptoms may be due to an

aggravation of medical problems such as neurological disorders (e.g., brain hemorrhage,

seizure disorder), infections (central nervous

system infection, pneumonia, AIDS­related

complications), and endocrine disorders (diabetes, hyperthyroidism). The presence of cognitive impairment (such as acute confusion,

disorientation, or memory impairment), unusual hallucinations (such as visual, olfactory, or

tactile), or signs of physical illness (such as

fever, marked weight loss, or slurred speech)

show a high risk for an acute medical illness.

Clients who exhibit this degree of risk need to

be referred immediately for a comprehensive

medical assessment.

Social risks

The primary goal is to ensure that clients have

access to adequate supports and that their basic

needs are met. Clients with COD involving psychosis are particularly vulnerable to homelessness, housing instability, victimization, poor

nutrition, and inadequate financial resources.

Clients who lack basic supports may require

aggressive crisis intervention, such as the provision of food and assistance with locating a safe

shelter. Lack of these social supports can be life

threatening and can exacerbate and intensify

both medical and psychiatric emergencies.

Figure D­11

Engaging the Client With Chronic Psychosis

Positive Engagement Techniques Coercive Engagement Techniques

• Assistance obtaining food, shelter, and clothing

• Assistance obtaining entitlements and social

services

• Drop­in centers as entry to treatment

• Recreational activities

• Low­stress, nonconfrontational approaches

• Outreach to client’s community

• Involuntary commitment

• Use of a representative payee

• Mandated medications

Specific Mental Disorders: Additional Guidance for the Counselor 391
Psychological risks	 

The primary goal of psychological assessments

must be an evaluation of the danger to self or

others and other manifestations of violent or

impulsive behavior. Clients with COD involving

psychosis have a higher risk for self­destructive

and violent behaviors, and should be assessed

for plans, intents, and means of carrying out

dangerous intent. Clients who are imminently

suicidal, homicidal, or otherwise pose a danger

need to be placed in a secure setting for further

assessment and treatment (see Figure D­12).

Some clients may have a cognitive impairment

related to their disorder and be unable to

attend adequately to basic needs. An assessment for these types of problems need to be

conducted by appropriately trained and experienced graduate­level professionals. When a

substance abuse counselor participates in these

assessment processes, he or she can provide

vital information on the client’s behavior and

emotional state.

Clinician’s observations

The clinician’s observations are an important

aspect of the assessment. The clinician should

make careful note of the client’s overall behavior, appearance, hygiene, speech, and gait. Of

particular interest are any acute changes in

these behaviors, as well as the emergence of

disorganized or bizarre thinking and behavior.

A long­term therapeutic relationship with the

client increases the opportunity to make clinical observations that assist in making the differential diagnosis. Within this context, clinicians can better understand the relationships

between the substance use and the symptoms of

mental disorders.

Collateral resources

As previously mentioned, data obtained from

direct interviews and self­reports, as well as

observational data, are limited. One important

way of augmenting these approaches is to

obtain information from collateral sources by

direct interviews with family members and significant others concerning the psychiatric and

substance­related behavior of clients. The family interview can also be a useful means of

obtaining further information regarding a family history of psychiatric and substance use disorders.

Useful documentation includes medical and

criminal justice records, as well as information

gathered from other sources such as landlords,

housing settings, social services, and employers. Case managers are in a unique position to

compile aggregate reports from these various

sources, since they follow clients over an

extended period of time in a variety of settings.

Laboratory tests

Laboratory tests for drug detection can be

valuable both in documenting substance use

and in assessing substance use in relation to

psychotic symptoms. Objective urine and blood

toxicology screens and alcohol Breathalyzer

tests can be useful. Besides being a diagnostic

Figure D­12

Biopsychosocial Assessment of High­Risk Conditions

Biological risks: Assess for life­threatening medical problems

Psychological risks: Assess for violent and impulsive behaviors

Social risks: Assess basic needs and life supports

Clients should be asked direct questions about past and current access to basic needs such as food, shelter,

money, medication, or clothing. Clients should be assessed for past and recent episodes of victimization and

of exchanging sex for money, drugs, and shelter.

392 Specific Mental Disorders: Additional Guidance for the Counselor
tool, data from urine screens may be particularly important for clients who deny regular

use of substances and who can benefit from

objective evidence of substance use. Toxicology

screens that document the absence of drug use

can provide positive feedback for abstinent

clients who are actively working to maintain

sobriety.

Social issues

While psychiatric, medical, or substanceinduced disorders may be more visible to the

clinician than social problems, the latter can

contribute significantly to the elaboration of

the disorder and to the client’s receptivity to

treatment. Indeed, the client with a co­occurring substance use disorder is more likely than

not to have significant impairment in the social

area. Thus, identifying the problem areas of a

specific client’s social life becomes a core component of the service or treatment plan.

Primary health care

A current or recent comprehensive medical

evaluation is an essential aspect of the overall

assessment for clients with psychotic disorders,

since they generally have a high prevalence of

medical problems. It is also important to evaluate the relationships between clients’ medical

problems and their psychotic and substance

use disorders. For example, medical problems

may: (1) coexist with co­occurring disorders,

(2) prompt or exacerbate psychotic and/or substance use disorders, or (3) be the direct or

indirect result of perpetuating co­occurring disorders.

It is especially important for these clients to

have easy access to treatment for medical conditions that are strongly associated with substance use, such as tuberculosis, hepatitis, diabetes, and HIV/AIDS. They should also have

easy access to primary care treatment for basic

medical needs, such as hypertension, as well as

cardiovascular, respiratory, and neurological

disorders. Prenatal care and monitoring should

be available to pregnant women who may be

especially at risk for relapse when her regular

antipsychotic medication regimen is contraindicated.

For clients who are taking prescribed medications, it is important to assess the types of medications, whether the medications are being

taken as prescribed, and the types of side

effects they may cause. Clients should be asked

specifically about the frequency, dosage, and

duration of any prescription medication.

Medication noncompliance is the rule, not the

exception, for people with co­occurring disorders. Psychiatric medication noncompliance is

particularly associated with co­occurring disorders that involve psychosis, and has a significant impact on presenting symptoms and level

of function. Because of this common association

between substance use and noncompliance, and

the limited utility of self­reports in this area,

prescribing physicians often order serum drug

level tests for psychiatric medications.

In addition to considering substance use as a

primary factor that affects the use of psychiatric medications, it is also important to consider the potential role of psychiatric medications

in subsequent substance use. For example, side

effects such as akathisia (severe restlessness) or

sedation may be caused by antipsychotic medications, and clients may take alcohol and/or

other drugs in an attempt to medicate these

unwanted side effects.

Frequently, clients spend money on psychoactive substances rather than on adequate and

nutritious food; the resulting nutritional

impairment can lead to impaired cognition. A

lack of regular meals and poor nutrition are

common occurrences among clients with COD;

therefore, access to regular meals should be

assessed. Acute dental problems as well as regular periodic dental care also should be

assessed. Because this group frequently experiences financial difficulties, dental care often is

limited or nonexistent. Attention should be

given to the social and emotional consequences

of poor dental health, such as poor self­esteem

and diminished social interaction.

Specific Mental Disorders: Additional Guidance for the Counselor 393
Crisis stabilization

The most important initial step in treatment is

to identify high­risk conditions that require

immediate attention. Within the area of acute

management it is useful to differentiate between

acute management of crises and the resolution

of subacute problems that may be severe but

not life threatening.

High­risk conditions

The initial critical consideration for high­risk

conditions is to determine if a client requires

emergency medical treatment, psychiatric

treatment, or both. If the client is found to

require hospitalization, it is then necessary to

determine the type of treatment that is

required (e.g., primary health care, detoxification, or psychiatric care). Such determinations

necessarily involve medical assessment and

intervention. Coordination with emergency

mental health services and the local police

department may be necessary to ensure the

immediate safety of the client and others.

Substance abuse treatment programs should

have clear and readily available policies and

procedures for addressing these situations, and

staff members should be thoroughly familiar

with their roles and responsibilities.

With regard to highrisk social conditions (homelessness,

housing instability,

victimization, and

unmet basic needs),

the priority is to

implement aggressive case management. Meeting

clients’ basic needs

is critical to the

treatment of COD,

including psychosis.

High­risk conditions

may be related to

medical, substance

use disorder, and/or

psychiatric crises,

and often will

require followup upon hospital discharge.

Regardless of the priority of the immediate

needs, the overall biopsychosocial needs of

clients must be addressed in a holistic manner,

considering both the psychosis and the substance use disorder. The approach must be

integrated and comprehensive despite the higher visibility of one of the disorders at a given

time.

Clients with severe

or persistent mental and substance

use disorders	 

require dually

focused, integrated

treatment.

Therapeutic coercion

Those clients with severe mental or substance

use disorders who do not respond to these initial attempts at engagement in the treatment

process may require the use of therapeutic

coercive approaches. Clients with severe COD

may have gross cognitive impairment due to

substance dependence and may be severely disorganized due to mental illness. They may be

impulsive, exhibit extremely poor judgment, or

be subject to repeated episodes in which they

are dangerous to themselves or others. Without

therapeutic coercive interventions, some of

these clients may be at substantial risk of catastrophic outcomes, including death, injury, violent behavior, or long­term incarceration.

Examples of therapeutic coercive approaches

include the appointment of a representative

payee, guardian, or conservator, and the use of

parole or probation. Legal advocacy by a case

manager for court­mandated treatment services

may be essential for engaging in and maintaining treatment services. Other mechanisms

include commitment to outpatient treatment

services, conditional discharge, and commitment to appropriate inpatient treatment.

Therapeutic coercive efforts should be temporary and reserved for clients for whom other

interventions have failed. The long­term goal

for these clients is to regain control over their

lives. Even when coercion is necessary, the

counselor can focus on the dangerous or harmful circumstances and avoid having the client

take commitment or other coercion as a sign of

personal failure, or as an indication of the

counselor rejecting the client. Although at the

time the client may protest, claiming to be mistreated and misunderstood, he or she often

394 Specific Mental Disorders: Additional Guidance for the Counselor
later expresses appreciation to the counselor

for the concern shown in seeing that the client’s

basic needs were met. This turnabout especially is likely when the counselor is able to convey

compassion and understanding (though not

agreement) throughout the process involving

coercive elements.

Short­term care and 

treatment

Following the resolution of the acute crisis,

subacute conditions must be addressed before

long­term management can occur. (Subacute

conditions can also occur as a precursor to

acute relapse of psychiatric symptomatology or

substance use.) Examples of specific management issues that may arise in regard to subacute conditions include resuming or adjusting

psychotropic medication, clients’ comfort with

the medication, medication compliance,

addressing acute psychiatric symptoms, establishing early substance abuse treatment intervention, and establishing or sustaining clients’

connection with support systems and services

for obtaining housing and meeting basic needs.

The subacute phase offers an opportunity to

reassess the diagnosis and overall treatment

needs. The ultimate goal should be to establish

a long­term treatment plan, avert imminent

decompensation or relapse, and plan to

address long­term needs. Both short­term and

long­term plans should be developed with the

client and should be subject to periodic review

and revision.

Group treatment

Group process is a core element of substance

abuse and mental health treatment. However,

for clients with psychosis, group treatment

should be modified and provided in coordination with a comprehensive service plan. Clients

who have accepted the goal of abstinence, have

maintained mental health stability, and have

essential social skills may benefit from carefully

selected traditional 12­Step programs that are

sensitive to the needs of people with serious

mental illness. However, during the early phases of treatment, an unfacilitated referral to traditional 12­Step programs could result in a

poor response. Fortunately, the growing movement for dual recovery mutual self­help groups

(as described in chapter 7) is providing an

attractive alternative for clients with COD. The

core approach should include psychoeducational, supportive, behaviorally oriented, and

skill­building activities.

Longer term care

The overall goal of long­term management

should involve: (1) providing comprehensive

and integrated services for both the mental and

substance use disorders, and (2) doing so with

a long­term focus that addresses biopsychosocial issues in accord with a treatment plan with

goals specific to a client’s situation. The following cases exemplify some of the diverse issues

that may arise in treatment planning.

Discussion of case examples

Louisa F. and James T. (see text box, p. 396)

have different long­term needs. Louisa F.’s

brief reactive psychosis and depression may

never recur, but the relationship between her

alcohol use and mental disorder symptoms

should be explored. James T.’s chronic psychosis and frequent substance abuse episodes

are woven together intricately and require

combined treatment.

These case examples are valuable to demonstrate how the absence of a dual­focus

approach can lead to treatment failure. While

Louisa F.’s psychotic episode was related to

overwhelming stress, her alcohol use might be

underemphasized in a traditional mental health

setting. Doing so may obscure the possibility

that her drinking severely deepened her

depression, increased daytime agitation, and

exacerbated the psychotic episode.

While James T. has ongoing psychosis and substance abuse problems, focusing on only one set

of these problems means that he bounces back

and forth between the mental health and substance abuse treatment programs, depending on

his current symptoms. His involvement with the

Specific Mental Disorders: Additional Guidance for the Counselor 395
Case Studies: The Importance of a Dual Recovery Approach

for Two Clients With Psychosis

Louisa F.

Married for more than 15 years, Louisa F. was responsible for most of the duties related to raising four children and maintaining the home. In the past, she had been treated for an episode of postpartum psychosis,

but until recently she had not required any psychiatric medications or mental health services.

Her husband, a successful businessman, was the family’s only source of financial support and was emotionally distant. While Louisa F. believed that her husband was frequently out of town on business trips, he was

actually nearby having an affair with a woman whom Louisa F. had known for many years. One day, he

abruptly informed Louisa F. of the affair and moved out of the house.

During the next 3 days, Louisa F. was intensely depressed and agitated. Her normally infrequent and lowdose alcohol use escalated as she attempted to diminish her agitation and insomnia. During this time, she ate

and slept very little. She began to feel extremely guilty for even the smallest problem experienced by her

four children. She felt burdened by what she called her “transgressions, faults, and sins.” She expressed

fears about being doomed to “eternal damnation.” Loudly and inconsolably, she declared that she “had lost

her soul” and would have to repent for the rest of her life. While being taken to a nearby clinic for evaluation, she passionately described a conspiracy by members of the Catholic Church to steal her soul.

James T.

In his inner­city neighborhood, James T. was well known by the local medical clinic, the substance abuse

treatment program, and the community mental health program. During the day he spent much of his time

walking around the neighborhood, frequently talking to himself or arguing with an unseen individual. He

spent most of his evenings in the park in a wooded area away from other people, except in the winter when

he slept in community­run shelters.

James T. has a prominent scar in the center of his forehead. When asked about it, he described in great

detail his “third eye,” and how he could see into the future through the eye. When asked about his stated

reluctance to live in an apartment, he described an aversion to “electromagnetic fields” that drain his “life

force” and make it difficult for him to “think about good things.” For extended periods lasting several

months, James T. appeared disheveled and agitated, and he could be seen drinking heavily or using whatever drugs were available. During other periods, he did not use drugs and alcohol heavily and appeared wellgroomed.

In general, James T. was pleasant and well­liked, although he was known to become hostile and potentially

violent when he used substances.

local medical clinic for treatment of physical

injuries that are sustained during episodes of

impaired thinking often complicates his already

uncoordinated treatment, especially if he is

given psychoactive agents for pain relief or what

seems to the medical clinic staff to be anxiety.

As these case examples illustrate, clients who

experience psychosis and substance abuse or

dependency often are highly symptomatic and

may have multiple psychosocial and behavioral

problems. It is common for such clients to have

undergone different approaches to treatment

by different providers without long­term success. Furthermore, clarifying the diagnosis and

“underlying disorder” is extremely complicated

in the early phases of assessment. The first step

in treatment of a person with COD is an assess396 Specific Mental Disorders: Additional Guidance for the Counselor
ment that addresses biological, psychological,

and social issues.

Clients with severe or persistent mental and

substance use disorders, such as James T.,

require dually focused, integrated treatment.

Clients like Louisa F., who have mild or brief

symptoms of mental illness, may benefit from

consultations, collaborations, and mutual selfhelp groups.

Long­term perspective

Both psychotic and substance use disorders

tend to be chronic disorders with multiple

relapses and remissions, supporting the need

for long­term treatment. For clients with COD

involving psychosis, a long­term approach is

imperative. Research has shown that individuals become abstinent and gain control over psychiatric symptoms through a process that frequently takes years, not days or months.

Front­loaded, intensive, expensive, and highly

stimulating short­term treatment modalities are

likely to have limited success with this group of

clients. Also, an accurate diagnosis and an

assessment of the role of substances in the

client’s psychosis necessitate a multiple­contact,

longitudinal assessment and treatment perspective.

Treatment teams

Especially for programs that treat clients with

psychotic and substance use disorders, it is

important that the program philosophy be

based on a multidisciplinary team approach.

Ideally, team members should be cross­trained,

and the team should include representatives

from the medical, mental health, and substance

abuse treatment systems. All staff members—

clinical, administrative, and operational—

should learn to use gentle or indirect confrontation techniques with these clients when

necessary. Many clients with co­occurring

schizophrenia require a temperate approach all

the time, and some people with bipolar disorder can take any criticism as an extreme insult,

particularly if they are experiencing the

grandiosity that often accompanies hypomanic,

manic, or residual states of the illness.

Assertive case management

Team members should endorse an assertive

case management approach, wherein the case

manager is expected to provide services to

clients in their own environments as well as at

the treatment site. The case manager must not

attempt to be the sole broker of treatment services or the exclusive provider of office­based

treatment. A supportive and psychotherapeutic

approach to individual, group, and family

work should be employed.

Flexible hours are necessary to provide services to these clients. Services need to be available during evening and weekend hours when

crises frequently occur. In addition, alternative

social activities and peer group activities often

take place in the evening and on weekends.

Using a behavioral and psychoeducational perspective

The individual and group programs for clients

whose COD involves psychosis should be based

on a behavioral and psychoeducational perspective, not a psychodynamic approach.

Educational information should be repeated

often and presented in concrete terms using a

multimedia format. Programs should be modified to include frequent breaks and shorter sessions than normal.

Special care should be taken with regard to

client education and group discussion about

“Higher Power” issues. If a program has this

focus, staff members should be trained to teach

clients and lead group discussions about spirituality and the concept of a Higher Power.

Staff members should understand the difference between spirituality and religion, and

especially the differences between spirituality,

religion, and delusional systems that have a

religious or spiritual content.

Associated psychosocial needs

Even intensive, carefully designed substance

abuse treatment is likely to have limited success

if the extensive psychosocial problems faced by

the client are not addressed concurrently.

Common psychosocial concerns of this group

include housing, finances and entitlements,

Specific Mental Disorders: Additional Guidance for the Counselor 397
legal services, job assistance, and access to adequate food, clothing, and medication.

A particularly common complication of clients

with psychosis and substance use disorders is

housing instability and homelessness. Among

the possible housing services that may be particularly useful are shelters, supervised housing

settings, congregated living settings, treatment

milieu settings, and therapeutic communities.

Ideally, residential options and placements

should be long term, with the goal of promoting

independent, stable, and safe housing.

However, short­term options that are less than

ideal should be explored to ensure the client’s

basic safety from weather and violence.

Vocational services

Vocational services also are essential for longterm stabilization and recovery. Both substance abuse and mental health services have

traditionally referred clients to generic vocational rehabilitation services; however, to be

effective these services must be integrated and

modified for the specialized needs of the individual with psychosis and substance use disorders. Temporary hire placements and job

coaching options are important elements to

incorporate into rehabilitation services for this

group.

Alternative support groups

An essential part of treatment for clients is the

development of alternative peer group relationships that do not include substance use.

Developing these non–substance­using social

networks can be enhanced by programs that

provide social club activities, recreational

activities, and drop­in centers onsite, as well as

linkages to other community­based social programs. At the same time, clients should be

encouraged to establish and maintain relationships, including family relationships, that are

supportive of treatment goals.

Family

Treatment can be substantially supported and

enhanced by direct involvement of the client’s

family. Services can include family psychoeducational groups that focus on education about

substance use disorders and psychosis, including those multifamily treatment groups that the

individual with the COD attends with his or her

family members.

Families also may be helpful in identifying

early signs of mental disorder or substance

use relapse symptoms. They can work with the

treatment team in initiating acute relapse prevention and intervention. Confidentiality3

needs to be addressed at the beginning of

treatment, with the goal of identifying a significant support person who has the client’s permission to be involved in the long­term treatment process.

Relapse prevention

An essential component of relapse prevention

and relapse management is close monitoring of

clients for signs of substance abuse relapse and

a return of psychotic symptoms. Relapse prevention also includes closely monitoring the

development of clients’ substance refusal skills

and their recognition of early signs of psychiatric problems and substance use. The goals of

relapse prevention are (1) identification of

clients’ relapse signs, (2) identification of the

causes of relapse, and (3) development of specific intervention strategies to interrupt the

relapse process.

Close monitoring involves the long­term observation of clients for early signs of impending

psychiatric relapse. Such signs may include the

emergence of paranoid symptoms and symptoms related to substance use, such as hostile

or disorganized behavior. For example, a sign

of paranoid symptoms may be the client’s sudden and constant use of sunglasses. Additional

important clues may involve changes in daily

3

Confidentiality is governed by the Federal “Confidentiality of Alcohol and Drug Abuse Patient Records” regulations (42

C.F.R. Part 2) and the Federal “Standards for Privacy of Individually Identifiable Health Information” (45 C.F.R.

Parts 160 and 164).

398 Specific Mental Disorders: Additional Guidance for the Counselor
routine, changes in social setting, loss of daily

structure, irritation with friends, and rejection

of help. Family members who reside with the

client often are the first to detect early signs of

psychotic or substance use relapse. Even routine daily stressors may have an intense impact

on the client with chronic psychosis and may

prompt relapse.

Objective laboratory tests also may be useful in

detecting relapse. These include the use of random urine toxicology screens, current noninvasive measures of alcohol use (e.g., saliva or

breath analysis), and blood tests to detect

street drugs. As medication noncompliance is

associated strongly with both substance use and

psychotic relapse, blood medication levels

(including antipsychotic and lithium levels)

particularly may be useful. Finally, the use of

intramuscular forms of antipsychotic medications may be particularly useful with very difficult noncompliant clients for ensuring longterm compliance with antipsychotic medications.

In addition to close monitoring by healthcare

professionals, family members, and significant

others, an important component of relapse prevention is assisting the client with developing

skills to anticipate the early warning signs of

mental and substance use disorders. These

skills can be acquired through direct individual

psychoeducation and participation in role­play

exercises and psychoeducation groups. These

clients should be trained in substance refusal

skills and to recognize situations that place

them at risk for substance use.

Similarly, these clients may benefit significantly

from behavioral therapy; development of relaxation, meditation, and biofeedback skills; exercise; use of visualization techniques; and use of

relapse prevention workbooks. Pharmacologic

strategies may include the use of disulfiram or

naltrexone for certain clients.

Weiss and colleagues (1999) have developed a

promising relapse prevention model for group

therapy with persons who have a bipolar disorder. The treatment consists of 20 weekly therapy

groups, each of which focuses on a topic relevant to both disorders. Topics include

(1) denial, ambivalence, and acceptance;

(2) self­help groups;

and (3) identifying and

fighting triggers. The

group is based on a

relapse prevention

model, which was

adapted to integrate

the treatment of bipolar and substance use

disorders by focusing

on similarities between

the recovery and

relapse processes for

each. For instance,

just as many people

with substance use disorders are tempted to abandon attempts at

abstinence after a “slip,” those with bipolar disorder may feel like stopping their medications

after experiencing a mood episode despite medication compliance. The group reviews strategies

for coping with a temporary setback in either

disorder, emphasizing the role of thoughts and

behaviors that can either improve or worsen

such a situation in either disorder. (For a more

detailed account of this approach see Weiss et al.

1999.)

An important component of relapse

prevention is helping

the client learn to

anticipate the early

warning signs of

mental and substance use disorders.

Medication

With clients who have COD that involve psychosis, lack of attention to medication issues is a

common provider mistake that often leads to

mental disorder or substance use relapse. Most

important, treatment programs must provide

aggressive treatment of medication side effects,

as ignoring the side effects of prescribed medication often results in clients using substances to

diminish such effects.

Equally important, clients should be educated

and thoroughly informed about (1) the specific

medication being prescribed, (2) the expected

results, (3) the medication’s time course, (4) possible medication side effects, and (5) the expected results of combined medication and substance use. Whenever possible, family members

Specific Mental Disorders: Additional Guidance for the Counselor 399
and significant others should be educated about

the medication.

Medication should not simply be prescribed or

provided to the client with psychosis. Rather, it

is critical to discuss with clients (1) their understanding of the purpose for the medication, (2)

their beliefs about the meaning of medication,

and (3) their understanding of the meaning of

compliance. It is important to ask clients what

they expect from the medication and what they

have been told about the medication. Overall, it

is important to understand the use of medication

from the client’s perspective. Indeed, informed

consent relative to a client’s use of medication

requires that the client have a thorough understanding of the medication as described above.

It also is important to help clients prepare for

peer reaction to the use of medication during

participation in certain 12­Step programs.

Clients should be taught to educate other people

who may have biases against prescription medications or who may be misinformed about

antipsychotic medications.

Ideally, clients receiving medication should participate in professionally led medication education groups and medication­specific peer support groups. These groups will help clients to

manage the emotional and social aspects of medication, promote medication compliance, and

help clinicians and clients identify and address

early noncompliance and side­effect problems.

Overall, a specific and aggressive treatment

strategy that helps make medication use simple

and comfortable is essential. The scheduling

and administration of medication should be

simple and convenient for clients. The ideal

schedule for oral medications is once per day.

The use of depot scheduling may be the most

comfortable and effective option for some

clients with COD involving psychosis.

Case Studies

Individuals with psychosis and substance use

disorders more often present for treatment in

the mental health setting. However, in some situations individuals with psychosis will report to

substance abuse treatment settings. For example, counselors may encounter a paranoid disorder that does not become apparent until the

client has been in treatment for some time, as

in the case study “A Hidden Psychosis.”

Case Study: A Hidden Psychosis

John R. was a 33­year­old client who had been treated for about 2 months in the substance abuse

treatment clinic. He was mostly quiet in treatment groups and had limited, though appropriate, social

interaction with his peers. His affect was somewhat restricted, but he initially denied a history of mental

health services. He was single, attended community college part time, and lived with his parents. During

the first 2 months he complained about somatic symptoms and cravings. During discussions in group

treatment, he started to become more vocal. He laughed inappropriately at times and often appeared to be

laughing quietly at his own jokes. Later, he confided in his therapist that he thought he was ugly and that

his nose was disfigured because he lied. He was also focused on the fact that he was 5 feet 5 inches; he

wanted to have a surgical procedure to increase his height because he would never get a girlfriend if he

wasn’t taller.

Discussion: Some cases of schizophrenia are mild and are only uncovered over time. A case this mild might be

treatable in the substance abuse treatment setting, with a consultation with the psychiatrist to evaluate the

need for medication.

400 Specific Mental Disorders: Additional Guidance for the Counselor
Case Study: Denial of Psychosis

Bob K. was a 31­year­old client who was homeless and living in and out of shelters. He stated that he

loved smoking pot but that the cocaine was taking a toll on him. Cocaine binges would cause him to hear

voices and become suspicious of others. Bob K. presented disheveled, with poor hygiene. He denied

prior mental health services and refused to see the psychiatrist because he didn’t want to be put on any

medications. He admitted later that he had some mental health services previously, but didn’t agree with

the therapist’s diag­nosis of schizophrenia. He did have periods of hallucinations and paranoia even

when he had not used cocaine for several weeks. He stated that the voices he heard were due to a bad

LSD trip when he was 21 years old and that since then God has been punishing him for doing drugs and

not listening to his mother.

Discussion: With an unmotivated client like Bob K., it is best to go easy and not challenge his belief

system head­on. The initial goal is to keep him in treatment, not to insist on his acceptance of the label of

“schizophrenic.” It would be best to assure him, for example, that even if his symptoms are a result of

drug use, medication could be helpful. The psychiatrist would do well to start him at a low dose of

medication, because he might bolt from treatment if he experienced side effects.

Case Study: Aftereffects of Drug Use

Sue P. was a 24­year­old who became extremely frightened and agitated upon returning from a “rave”

party. Her mother brought her to the emergency room because of her daughter’s strange behaviors and

odd comments. Sue was a college graduate who was working in sales and living at home. She wanted to

stay in a fetal position, was fearful of others, and worried that the police had planted listening devices in

her home. After about 48 hours Sue was less paranoid and more relaxed. She then was able to admit to

doing ecstasy and ketamine at the rave.

Discussion: Sue will probably recover well in a quiet room with supervision, possibly from her mother or

possibly as an inpatient. She should have a low dose of antipsychotic medication for about a week and

should be carefully assessed for suicidal tendencies. She should be told clearly that the effects she is experiencing are the result of drug use.

Case Study: Counseling a Binge Drinker With Bipolar

Disorder

Francisco H. has come for treatment after losing his job because of binge drinking. Francisco H. has little

energy and his voice is so low the counselor can barely hear it. Probing for depression, the counselor learns

that Francisco H. has at least five symptoms of depression and has previously been diagnosed as having

bipolar disorder. He says he sometimes drinks to calm down “when he’s flying too fast.” However, he has

not taken his medication regularly and believes if he can just stop drinking he will be fine. He has been

attending AA meetings sporadically and has been told that medication is just another form of drug.

The counselor gives Francisco H. a brochure from AA on medication for mental illness (Alcoholics

Anonymous World Services 1984). He points out that acceptance of medication is an important step in

recovery, suggesting that Francisco H.’s bipolar disorder and alcohol abuse interact with each other. Using

Specific Mental Disorders: Additional Guidance for the Counselor 401
Case Study: Counseling a Binge Drinker With Bipolar

Disorder (continued)

motivational interviewing techniques, he finds that Francisco H.’s major concern is his need for work; his

wife is pregnant, and his loss of a job has put the family in a precarious position. He suggests that taking the

medication will help Francisco H. level out mentally and enable him to seek employment. If he uses the medication consistently along with other recovery supports, including a 12­Step group that meets at the center,

he may be able to break the interactive cycle between the two disorders. The counselor cautions that 3 or 4

weeks may be needed to feel the full effects of the medication and alerts him to the possibility of side effects,

which should be reported immediately. He lets him know, however, that if Francisco H. does experience side

effects with one antidepressant, he may be able to take others. Francisco H. accepts a consultation with the

psychiatrist to explore the possibility of medication.

Discussion: Often, a client is motivated to address one disorder but not the other. The counselor should help

the client recognize the possible relationship between the two. When the use of medication is a concern, the

counselor should be prepared to explain the difference between drugging or drinking to get high and using a

prescription drug to stay at a normal level of functioning. AA literature that addresses this topic is often

helpful (see appendix J for information).

Attention

Deficit/Hyperactivity

Disorder (AD/HD)

Description

AD/HD is “a persistent pattern of inattention

and/or hyperactivity­impulsivity that is more

frequently displayed and more severe than typically is observed in individuals at a comparable level of development” (APA 2000, p. 85).

People with AD/HD may fail to give close attention to details, be easily distracted, shift among

activities without completing tasks, have disorganized work habits, and forget obligations.

Hyperactivity may be indicated by “fidgetiness,” difficulty engaging in quiet activities,

and general restlessness. Individuals with

AD/HD may be impatient and engage in dangerous activities without thinking of the consequences. Strictly speaking, those with attention

deficit do not have a deficit in attention but “a

lack of consistency in direction and control.”

They have been described as “attending to

everything” (Waid et al. 1998, p. 394). Often,

individuals with AD/HD have poor selfesteem, are demoralized, and may be rejected

by their peers.

Symptoms of this disorder are most likely to be

evident in a group setting. Usually symptoms

lessen as children mature, though adults may

continue to have difficulty participating in

sedentary activities. Many adults diagnosed

with AD/HD complain of having a hot temper,

low self­esteem, inability to relax, inability to

complete tasks, poor driving skills, family violence, and difficulty sustaining jobs or relationships. Their key “neuropsychological weakness” has been termed “executive dysfunction,”

which includes difficulties with planning,

sequencing, and organizing activities. Some

adults with AD/HD learn to channel their energy into sports­related activities or find other

means of coping with the disorder.

There are three types of AD/HD: a “combined

type” in which a person has both difficulty

paying attention and hyperactivity, a type that

is “predominantly inattentive,” and a type that

is “predominantly hyperactive­impulsive.” It is

important to note that “the validity of the diagnosis of AD/HD, particularly in adults, has

been questioned” (Waid et al. 1998, p. 393).

However, AD/HD is now recognized as a disorder by DSM­IV, the standard guidance on diagnosis for mental disorders (APA 2000).

402 Specific Mental Disorders: Additional Guidance for the Counselor
Symptom clusters for inattention and for

hyperactivity­impulsivity are illustrated in

Figures D­13 and D­14.

Differential Diagnosis

A number of other mental disorders may produce symptoms similar to AD/HD, including

substance­related cognitive impairment, bipolar disorder, major depression, anxiety disorder, dissociative identity disorders, social phobia, and personality disorders, especially

obsessive­compulsive personality disorder.

AD/HD must also be distinguished from personality change that may occur as a result of a

medical condition, such as a stroke, head trauma, or hypothyroidism. Both alcohol and marijuana abuse can produce symptoms that mimic

AD/HD.

It is important to rule out other causes of inattention or hyperactivity. People with substance

use disorders who are newly abstinent or those

in active or protracted withdrawal may experience some impairments similar to AD/HD.

Some persons with low IQs may also exhibit

AD/HD symptoms.

Further adequate assessment and treatment for

potential withdrawal syndromes should occur

before concluding that the client is either cognitively impaired or has AD/HD (see also TIP 29,

Figure D­13

AD/HD Symptom Cluster:

Inattention

• Failure to attend to detail, careless mistakes

• Difficulty sustaining attention

• Does not listen

• Poor follow through, failure to finish

• Difficulty organizing tasks and activities

• Avoidance of effort­demanding tasks

• Losing things

• Easily distracted

• Forgetful in daily activities

Figure D­14

AD/HD Symptom Cluster:

Hyperactivity­Impulsivity

• Fidgets, squirms

• Unable to remain seated

• Runs or climbs excessively (restless in adults)

• Inability to play (relax) quietly

• “On the go,” “driven by a motor”

• Talks excessively

• Blurts out answers

• Can’t wait for turn

• Interrupts, intrudes

Substance Use Disorder Treatment for People

with Physical and Cognitive Disabilities [CSAT

1998e]). Keys to reliable diagnosis of AD/HD in

adults include the following:

• Childhood history

• Corroboration by an outside source

• Proof of impairment, such as problems with

certain types of work or study

• Persistence of symptoms over time without

fluctuation

• Taking into account the effect of the context

(e.g., inability to focus on reading matter in a

crowded, noisy subway car does not imply

AD/HD)

• Cognitive testing

• Questionnaires

Prevalence

A recent review reports the prevalence of

AD/HD among children as wide as 2 to 19 percent (Rowland et al. 2002). Between 10 and 65

percent of individuals who have AD/HD as children continue to have debilitating symptoms of

the disorder as adults (Waid et al. 1998).

Studies of the adult substance abuse treatment

population have found AD/HD in 5 to 25 percent of persons, suggesting that about one in six

clients may have this co­occurring problem

Specific Mental Disorders: Additional Guidance for the Counselor 403
(Clure et al. 1999; King et al. 1999; Levin et al.

1998; Schubiner et al. 2000; Weiss et al. 1998).

Waid and colleagues (1998) estimate that 33

percent of adults with AD/HD have histories of

alcohol abuse or dependence, and 20 percent

have other drug abuse or dependence histories.

A history of childhood AD/HD has been found

in 17 to 50 percent of people with substance use

disorders and from 17 to 45 percent in people

who abuse cocaine and opioids (Waid et al.

1998). Adults with persistent symptoms of

AD/HD who have a history of conduct disorder

or have co­occurring APD are at the highest

risk for having substance use disorders as well.

Substance Abuse and

Dependence Among Adults

With AD/HD

Adults with AD/HD have been found to abuse

primarily alcohol, with marijuana being the

second most common drug of abuse (Waid et al.

1998). While early studies hypothesized that

these clients used stimulants in an effort to selfmedicate, their preferences seem to be the same

as those of the general population (Waid et al.

1998). The relationship between AD/HD and

substance use disorders is important because

“clients with these combined disorders may

require and respond differentially to various

therapeutic approaches” (Waid et al. 1998, p.

393). The presence of AD/HD complicates the

treatment of substance abuse, since clients with

these co­occurring disorders have “more treatment difficulties, poorer substance abuse treatment outcomes, and a greater risk for relapse

than clients diagnosed with substance use disorder alone” (Waid et al. 1998, p. 412).

Obviously, such clients have more trouble in

didactic, lengthy sessions that require focus

and sustained attention.

Key Issues and Concerns

Though controversial, AD/HD appears to be a

real disorder and must be considered seriously

as a possibility for clients who show the symptom clusters depicted in Figures D­13 and D­14

(p. 403).

Though stimulants are the pharmacological
 

treatment of choice for AD/HD in children,
 

clinicians should be aware that antidepressants
 

such as bupropion or desipramine are preferable for chemically dependent adults.
 

Research is lacking on longer term outcomes,
 

and better biopsychosocial treatments remain
 

to be developed.
 

Strategies, Tools, and

Techniques

Engagement

During engagement, a problem can emerge if

the client divulges a previous AD/HD diagnosis

to a counselor who does not believe the problem exists. Another problem can occur if the

client has the hyperactive version of AD/HD,

which makes interaction difficult, and poses

many of the same challenges as hypomanic

clients. Such clients have trouble staying

focused and maintaining a dialogue. Eliciting

information and keeping the client on task for

the duration of the intake interview is difficult.

These clients may have a “short fuse” and

become irritable when the counselor has to

bring them back to the intake process repeatedly. During group, this type of behavior and

habitual side conversations can lead to intragroup conflict.

These engagement problems are in fact the

beginning stages of differential diagnosis and

assessment. Adult AD/HD has not been widely

recognized or accepted in either the substance

abuse or mental health treatment communities,

but occupies a position similar to that of PTSD

in the last decade—clients with complaints, a

small amount of research, and often active

resistance by therapists to acknowledging that

AD/HD is a real disorder. Substance abuse

treatment counselors who hear clients say, “I

was just self­medicating my AD/HD with

cocaine,” as a convenient rationalization for

substance abuse may be even more suspicious,

but about one in six of these “rationalizers”

may have real attention deficit problems that

undermine their treatment and abstinence. At

404 Specific Mental Disorders: Additional Guidance for the Counselor
this stage, the best engagement strategy for

such clients is to keep an open mind to the possibility the client does have AD/HD and develop services or referrals for clients who are

legitimately affected by AD/HD.

Engaging the hyperactive client

The counselor may use an adapted form of

motivational techniques for the invasive,

talkative, hyperactive client. The counselor

might tell the client which elements of discussion he or she has successfully completed, then

reframe the remainder. For example, during

the initial intake question concerning what it

was that brought the client to the clinic, a client

may begin to talk about his alcohol and marijuana use, but rapidly move into a discussion

of the argument he and his wife have been having about his poor work history (he gets jobs

but then loses them), then switch to talking

about what is wrong with the automobile industry in the United States and pollution control.

After a few attempts to redirect, the counselor

is left thinking, “How can I get this guy to

focus? Why does he talk so fast and always

ends up off­topic? Is this denial, resistance,

hypomania, or attention deficit disorder?”

In such a situation, the counselor might

respond, “You sure pack a lot of information

into one answer. It’s hard for me to keep up!

So can we take things a bit slower? Now, let’s

go back to when you first started to use alcohol.” In this case, the client with AD/HD will

more likely be able to focus with frequent gentle reminders. The hypomanic client will most

likely keep “revving up” and require more

active management. The school histories of

these two clients should be different, with the

client with AD/HD showing early school problems before substance abuse began.

The presence

of AD/HD

complicates the

treatment of

substance abuse.

Screening and assessment

Strictly speaking, it is not possible to diagnose

an adult as having AD/HD unless there is a

childhood history of the disorder. Basic screening for this possibility can be as simple as asking, “When you were in grade school, before

you used drugs or alcohol, did you have learning or behavior problems? Were you ever diagnosed with AD/HD? Did you ever take medications for this? How much did the medications

help?”

The clinician is advised to “focus on the primary symptoms of inattention, impulsivity, and

hyperactivity because secondary symptoms

such as procrastination, disorganization, forgetfulness, chronic lateness, or underachievement do not necessarily indicate that the client

suffers from AD/HD” (Waid et al. 1998, p.

406).

Since people with substance use disorders are

not always good historians, whenever possible

it is useful to interview others who knew them

well as children. Evidence should also be

sought “via review of records, reports from

parents or significant others, and use of behavioral checklists and questionnaires” (Waid et

al. 1998, p. 412). Scales and checklists currently available for use in assessing behavioral

symptoms of AD/HD include the HyperkinesisMinimal Brain Dysfunction Childhood

Symptom Checklist, the Wender Utah Rating

Scale (Ward et al. 1993), the Client Behavior

Checklist, and the Conners Abbreviated

Symptom Questionnaire. When using these

instruments, the clinician should be aware that

they have not been

validated for use in

substance­abusing

populations.

There is no “definitive

test battery” to assess

the neuropsychological impairments associated with AD/HD,

but much can be

learned by observing

clients’ behavior in

testing situations.

Frequent false starts,

off­task behavior, and

concentration problems are suggestive

(Waid et al. 1998),

and continuous perSpecific Mental Disorders: Additional Guidance for the Counselor 405
formance tests—the

Gordon Diagnostic

System (GDS), the

Test of Variables of

Attention (TOVA),

and the Conners

Continuous

Performance Test—

can be used to measure distractibility.

The most common

attention problems

in people with substance use disorders

occur as a result of

short­term toxic

effects of substances.

Such difficulties

should improve with

each month of abstinence. With this in mind,

Waid and colleagues suggest that “frequent

reassessments as abstinence is maintained may

result in the detection or disappearance of

other psychiatric and cognitive disorders,

including learning disabilities” (Waid et al.

1998, p. 415). If attention symptoms do not

improve over time, the client should be

referred for further assessment.

Education about

AD/HD may be

useful and

enlightening to

many clients.

Crisis stabilization

Adult AD/HD is not an emergency condition.

Rather, it usually is chronic, subtle, and difficult to separate from the client’s substance use

or its consequences. The most likely crisis that

might emerge is from the significant abuse of

prescription stimulants obtained illegally or

from a doctor outside the client’s established

healthcare providers. For example, a client

might arrive at a group intoxicated, on stimulants, hyperactive, and evasive. The client

might have a positive urine test, but refuse to

accept the incident as serious because “the

medication was prescribed.” The second part

of the crisis would then require consultation

with the outside prescribing doctor; the client

must sign a consent form for the release of

information held by this doctor.

If the client is found to be taking psychoactive

and abusable prescription medications such as

amphetamines, Ritalin, and pemoline outside

of the substance abuse treatment agency treatment plan, an immediate treatment conference

is needed to determine and discuss

• Client safety: Does the client need hospitalization or detoxification?

• If not, is the client willing to discontinue the

outside medications and continue substance

abuse treatment?

Preferably, medical personnel at the substance

abuse treatment agency will obtain the appropriate consent from the client, contact the outside doctor, discuss the case, and make the best

clinical decisions around the welfare of the

client. This typically includes consideration of

other, nonabusable AD/HD medications such

as bupropion or desipramine, preferably prescribed by internal agency substance abuse

treatment staff (if available).

Short­term care and 

treatment

Unless the client already has been diagnosed

with valid AD/HD, which is possible but rare,

AD/HD cognitive and behavioral problems

begin to become apparent during this initial

phase of treatment. Poor attention and impulsive behavior are most likely due to continued

substance use or withdrawal; however, if the

client is found to be clean and has no history of

a mental disorder, then AD/HD should be considered, and the client should be referred to an

expert diagnostician. Since AD/HD expert diagnosticians are rare, especially as available to

substance abuse treatment agencies, the field

faces a serious challenge. Individual clinicians

need to do the best they can with their limited

resources.

Factors leading to underdiagnosis of AD/HD at

this stage include

• Reluctance on the part of staff or the client to

considering or accepting the diagnosis, or

lack of familiarity with the disorder.

406 Specific Mental Disorders: Additional Guidance for the Counselor
• Difficulties stemming from the client’s lack of

recall or having no family to help with the

diagnosis of a childhood AD/HD condition,

whether or not the diagnosis was made officially.

• The client’s life habits have compensated

partially for AD/HD symptoms, though

AD/HD was present in childhood and symptoms may emerge in the treatment process.

Factors leading to overdiagnosis include

• Attributing cognitive or behavioral abnormalities prematurely to AD/HD, rather than

considering the most usual causes (continued

substance use, withdrawal, or other disorders noted above).

• Using results of standardized screens such as

the AD/HD Behavior Checklist for Adults

without considering that many positive

responses can be caused by substance use or

other mental disorders.

Assuming that the AD/HD diagnosis is reasonably and accurately made, sensible treatment

for adults with co­occurring substance dependence and AD/HD include the following:

• Abstinence from substances of abuse or

dependence.

• A psychosocial treatment plan that takes into

account the client’s AD/HD profile—for

example, an increased use of visual aids

(Dansereau et al. 1995; Dees et al. 1994).

• The use of medications to increase attention.

Though substance­dependent AD/HD clients

may be able to take abusable stimulants in highly monitored clinics, much as opioid­dependent

clients can take methadone in highly controlled

clinics, this approach should not be attempted

by other substance abuse treatment clinics.

Rather, when medication is indicated, bupropion, tricyclics such as desipramine, or other

antidepressants should be used. These medications have been found to be about as effective as

stimulants, but are not abusable and have little

if any street value. The substance abuse treatment counselor helps to monitor compliance,

asks about side effects, and communicates any

clinical responses to the prescriber.

Case management

Case management of suspected adult AD/HD

begins by arranging adequate diagnostic assessment. If AD/HD is confirmed as the co­occurring disorder, the counselor should employ the

elements of treatment as discussed below in this

section (see “Adapting Mental Health and

Substance Abuse Treatment Approaches”) and

monitor outcomes over time.

Psychoeducation

Education about AD/HD may be useful and

enlightening to many clients; self­help books

and AD/HD support groups also can be very

helpful (Waid et al. 1998). Waid and colleagues

suggest that “modalities other than

auditory/verbal ones may be constructive in

this population” (Waid et al. 1998, p. 413). For

example, consider the use of pamphlets (especially those with diagrams and pictographs)

and dramatic videos. In fact, many of the typical alternatives used in standard substance

abuse treatment—Alcoholics Anonymous meetings (60 to 90 minutes versus all­day classes),

dramatic videos (versus textbooks), relapse

diagrams, and standardized short group checkins—help to focus those with impaired attention rather than overwhelm them with details.

Adapting mental health and substance abuse treatment approaches

Waid and colleagues recommend “structured

and goal­directed sessions, with the therapist

actively enhancing the client’s knowledge about

AD/HD and substance abuse and examining

false beliefs about the history of his or her difficulties” to “serve as the framework for an

effective intervention” (Waid et al. 1998, p.

413). They caution that “long verbal

exchanges, extended group therapy, and overstimulating environments should be avoided, as

they often overtax the AD/HD substance abusing client” (Waid et al. 1998, p. 413). Frequent

brief sessions are preferable to a few long

intense ones. The usual 3 hours, three times

weekly in Intensive Outpatient Programs will

be difficult for many people with AD/HD, even

when the AD/HD is being treated. These clients

should be assigned to therapists knowledgeable

Specific Mental Disorders: Additional Guidance for the Counselor 407
about both disorders so that appropriate

adjustments in treatment strategies can be

made as needed.

Longer term care

Even if response to medications and structure

occurs, the effects may be subtle and slow to

develop—it is primarily in longer term care

that the real benefit of integrated AD/HD care

emerges. The client will be more likely to stay

sober and in treatment within the framework of

longer term care. Gradually, the impulsiveness

and inattention should lessen. Coaching about

how to handle taking medications while attending 12­Step or other mutual self­help programs

also may be advisable.

Posttraumatic Stress

Disorder

Description

PTSD follows the experience of a psychologically traumatic stressor such as witnessing

death, being threatened with death or injury,

or being sexually abused. At the time of the

stressful event, the individual experiences

intense fear, helplessness, or horror. PTSD

entails three sets of symptoms that last longer

than 1 month and result in a decline in functioning (e.g., work, social):

• Intrusion: a persistent reexperiencing of the

trauma in the form of intrusive images and

thoughts, recurrent nightmares, or experiencing episodes during which the trauma is

relived, as in flashbacks

• Avoidance: persistent avoidance of stimuli

related to the trauma such as activities, feelings, and thoughts associated with the traumatic event

• Arousal: persistent symptoms of increased

arousal such as insomnia, irritability, hypervigilance, and exaggerated startle response

Many physical, cognitive, and emotional disruptions can occur in response to an acute

traumatic event and/or PTSD. The DSM­IVTR (APA 2000, p. 465) lists the following associated descriptive features:

• Impaired affect modulation

• Self­destructive and impulsive behavior

• Dissociative symptoms (Note: Dissociation

represents a psychic defense in which a person is so overwhelmed by a traumatic memory or feeling that the mind simply “shuts

down,” literally removing itself [disassociating] from the present reality. The person may

become suddenly quiet, or stare into space,

as if they have entered a trance. Patients

have described dissociation as “being out of

it,” “losing time,” or “floating away.”)

• Somatic complaints

• Feelings of ineffectiveness, shame, despair, or

hopelessness

• Feeling permanently damaged

• A loss of previously sustained beliefs

• Hostility

• Social withdrawal

• Feeling constantly threatened

• Impaired relationships with others

• Change from the individual’s previous personality characteristics

The two conditions may coexist for decades,

particularly if both disorders are not addressed

adequately in treatment. Interest in the role of

trauma and PTSD have increased with the

recognition that they are common among substance abuse clients. This co­occurring disorder is particularly prevalent among women,

who typically experienced childhood physical

or sexual abuse. It also is prevalent in combat

veterans and many veterans’ hospitals have

PTSD treatment units (Forbes et al. 2003;

Steindl et al. 2003). The Department of

Veterans Affairs’ National Center for PTSD

has been a leading clinical and research

resource for both the trauma and substance

abuse fields (see the forthcoming TIP

Substance Abuse Treatment and Trauma

[CSAT in development d]).

408 Specific Mental Disorders: Additional Guidance for the Counselor
Prevalence

Community­based studies indicate the lifetime

prevalence of PTSD among adults in the

United States is about 8 percent (APA 2000).

Among high­risk individuals (those who have

survived “rape, military combat and captivity”

or “ethnically or politically motivated internment and genocide”), the proportion of those

with PTSD ranges from one­third to one­half

(APA 2000, p. 466).

Among clients in substance abuse treatment,

this co­occurring disorder is two to three times

more common in women than in men (Brown

and Wolfe 1994). The rate of PTSD among people with substance use disorders is 12 to 34 percent; for women who abuse substances, it is 30

to 59 percent. A review of the literature found

that PTSD often goes undetected due to lack of

screening (Leskin et al. 1999). See below for

suggestions on conducting a basic screening for

PTSD.

Most women with this co­occurring disorder

experienced childhood physical and/or sexual

abuse; men with both disorders typically experienced crime victimization or war trauma

(Kessler et al. 1995). Clients sometimes are perceived as “crazy,” “lazy,” or “bad” by others

and by themselves (Najavits 2002). They may

carry a great burden of shame and guilt, as

both PTSD and substance abuse may be associated with keeping secrets and denial. Clinicians

are advised not to overlook the possibility of

PTSD in men; in Kessler’s major study of a

community sample, rates for men were higher

than for women (Kessler et al. 1995).

People with PTSD and substance abuse also are

more likely to experience another trauma than

people with substance abuse alone (Dansky et

al. 1998). Repeated trauma is common in

domestic violence, child abuse, and some substance abuse lifestyles (e.g., the drug trade).

Helping protect the client against future trauma

may be an important part of work in treatment.

It is also noteworthy that in a high percentage

of rape cases (37.9 percent), those who perpetrated the violent assault were using substances

at the time (Bureau of Justice Statistics 2002).

Many physical,
 

cognitive, and emotional disruptions

can occur in

response to

an acute

traumatic event

and/or PTSD.

Substance Abuse and

Dependence Among People

With PTSD

People with PTSD tend to abuse the most
 

addictive substances (cocaine and opioids);
 

however, abuse of prescription medications,
 

marijuana, and alcohol also is common.
 

Substance abuse often is viewed as “self­medication” to cope with the overwhelming emotional pain of PTSD (Chilcoat and Breslau 1998b;
 

Cottler et al. 1992; Goldenberg et al. 1995;
 

Grice et al. 1995; Najavits et al. 1997). From
 

the client’s perspective, PTSD symptoms are a
 

common trigger of
 

substance use (Brown
 

et al. 1995). The combination of PTSD and
 

substance abuse may
 

present in combat veterans, those with

acute PTSD related to

terrorist attacks,

those with chronic

PTSD related to

childhood events, and

others (Breslau et al.

2003; Forbes et al.

2003; Grieger et al.

2003; Riggs et al.

2003; Simpson 2003;

Steindl et al. 2003).

While under the influence of substances, a

person may be more

vulnerable to trauma—for example, the woman

drinking at a bar who goes home with a

stranger and is assaulted.

As a counselor, it is important to recognize—

and help clients to understand—that becoming

abstinent from substances does not resolve

PTSD; indeed, some PTSD symptoms might

become worse with abstinence at first (Brady et

al. 1994; Kofoed et al. 1993; Root 1989). As

clients give up substance use, they may be

overwhelmed by a flood of memories and feelings that their substance use had kept at bay.

“You will feel better once you are clean and

Specific Mental Disorders: Additional Guidance for the Counselor 409
sober” is not an accurate message to give a

client with PTSD and substance use disorders.

A more accurate statement would be, “Getting

clean and sober will help you, but initially you

may find yourself facing feelings and memories

of your trauma. We can get through this together, and eventually you can achieve recovery

from both the substance abuse and PTSD

issues.”

A variety of medications are used in the treatment of PTSD, and since other anxiety disorders (often panic, generalized anxiety) and

mood disorders (major depression, dysthymia,

bipolar II) often accompany PTSD, patients

can be on several medications at once, most

often an antidepressant, such as a sertraline or

paroxetine (SSRIs—see appendix F, Common

Medications for Disorders), which is frequently

combined with a sedative medication, such as

an anticonvulsant, or even an antipsychotic

(Ballenger et al. 2004; Davidson 2004).

Especially as a client with PTSD becomes abstinent, medications targeting mood, anxiety, or

severe nightmares may be of crucial importance. While benzodiazepines such as clonazepam and alprazolam often have been prescribed to such clients for anxiety, and though a

few case reports exist that document the safe

use of these medications, the consensus panel

recommends that

benzodiazepines usually be avoided, as

panel members have

observed a great

many problems with

the use of benzodiazepines. Consensus

panel members

reported their own

experiences with

clients who abused

benzodiazepines—

clients experienced

escalating tolerance,

had periods of confusion, and became

dependent on a medication that is among

the most dangerous

in its withdrawal symptoms (seizures, etc.),

especially if used along with alcohol, as it often

is. Recent research has found both prazocin

and propranolol, which are older, generic antihypertensives that decrease overactivity in the

autonomic nervous system, to hold great

promise in decreasing nightmares and flashbacks (Raskind et al. 2002, 2003; Vaiva et al.

2003).

Several

well­developed,

research­based,

and clinically	 

tested models of

treatment exist for

PTSD.

Key Issues and Concerns

Treatment of PTSD with co­occurring substance use disorders requires careful planning

and supervision. As the client faces painful

trauma memories, the desire for intoxication

can be overwhelming. By exploring trauma

memories, well­intentioned counselors inadvertently may drive a client back to the substance

by urging her to “tell her story” or “let out the

abuse.” Even if a client wants to talk about

trauma and seems safe during the session,

after­effects may well ensue, including a flood

of memories she is not prepared to handle,

increased suicidality, and “retraumatization”

where she feels as though she is reliving the

event. Such treatment approaches should be

undertaken only with adequate formal training

in both PTSD and substance abuse and only

under careful clinical supervision.

These clients need stability in their primary

therapeutic relationship; hence, this work

should not be undertaken in settings with high

staff turnover, and should never be undertaken

without training and supervision. The substance abuse counselor should not try to provide trauma­exploration treatment, in view of

the potential for highly destabilizing effects

(including worsening of substance use).

However, the substance counselor can play an

important role in helping to identify PTSD and

in providing present­focused psychoeducation

about PSTD, such as teaching the client to recognize symptoms of the disorder and how to

cope with them. For severe cases of PTSD,

treatment typically is long term.

Several well­developed, research­based, and

clinically tested models of treatment exist for

410 Specific Mental Disorders: Additional Guidance for the Counselor
PTSD (for example and reviews, see Foa et al.

2000; Follette et al. 1998; Yehuda 2002). Some

of these models are particularly suited for use

with clients who also have a substance use disorder (such as the Seeking Safety model discussed below). For example, the Trauma

Adaptive Recovery Group Education and

Therapy (TARGET) (Ford et al. 2000) has

developed a strengths­based approach to education and skills training for trauma survivors

that presents a seven­step approach both for

changing the PTSD alarm response and for

relapse prevention during each of the sessions.

Other models (e.g., Abueg and Fairbank 1992;

Klever and Brom 1992) are eclectic—that is,

they mix a variety of strategies, techniques,

and models. Several of these eclectic approaches and various research studies focus on specific interventions or problems, such as Meisler

(1999) on group therapy for PTSD with alcohol

abuse; Brady et al. (1995) on the possible use

of sertraline; and Nishith et al. (2003) regarding alcohol use for sleep by female rape victims.

Of course, this brief review of models barely

begins to cover the immense amount of work

related to trauma and substance abuse. Many

people working with clients on issues of childhood abuses have long known of the importance of including substance abuse in treatment

(e.g., Covington 2003; Evans and Sullivan

1995; Trotter 1992). For more information, see

the forthcoming TIP Substance Abuse

Treatment and Trauma (CSAT in development d).

The following sections are based on the Seeking

Safety (Najavits 2002) model, which the consensus panel deems a practical and helpful

approach for most counselors. While Seeking

Safety was developed for women, the consensus

panel feels it is broadly appropriate for both

men and women with PTSD and co­occurring

substance use disorders. Several issues need to

be considered when working with PTSD/substance abuse treatment clients:

• Develop a plan for increased safety where

appropriate (e.g., this is less critical for

chronic PTSD secondary to childhood trauma or war trauma)

• Establish trust

• “Listen” to a client’s behavior even more

than his or her words

• Recognize that a client with PTSD and substance use disorder may have a more difficult

time in treatment

• Help the client access treatment for PTSD

• Recognize the importance of one’s own trauma history

• Help the client learn to de­escalate intense

emotions

• Reinforce the taking of appropriate medications

Develop a plan for increased safety. Some

clients with PTSD have a variety of safety

issues, including risk for further trauma, suicidality, and self­destructive behavior (e.g., selfharm such as cutting, unsafe sex that may lead

to HIV, and involvement with people who

exploit them). Helping the client become aware

of these patterns, and identifying concrete

actions the client can use to cope with them,

may be highly beneficial. For example, a client

who is living with a partner who is battering

her (domestic violence) needs careful assistance, often through consultation with a domestic violence hotline or other expert who can

help advise on this difficult situation (see TIP

25, Substance Abuse Treatment and Domestic

Violence [CSAT 1997c]). See below for specific

treatment resources for safety­oriented work

with people with PTSD.

Establish trust. Sometimes clients who have

lived through trauma have difficulty trusting

others. The trauma may have been a violation

of an important relationship (e.g., in child

abuse or domestic violence), or the trauma may

have felt like something that could not be

talked about (e.g., war, rape). Substance

abuse, too, may have isolated the client.

Therefore, a key element of successful treatment involves helping the client build trust,

never forcing her to talk about something she

does not want to, asking permission to talk

about sensitive issues, conveying respect and

empathy in tone, avoiding harsh confrontation,

Specific Mental Disorders: Additional Guidance for the Counselor 411
and generally acting as her advocate and ally,

even when difficult behaviors arise.

“Listen” to a client’s behavior even more than

words. Clients with PTSD often are not fully

conscious of the depth of their inner feelings.

They may be prone to internal “splitting” as

well, where their feeling­states are not integrated (e.g., they shift between anger and depression). They may find themselves acting in ways

that suddenly “happen,” rather than acting in

ways that are chosen. They also may keep their

feelings to themselves out of the fear of burdening others. Monitoring the client’s actual

behaviors is key: Is she using substances more

or less? Is he showing up for treatment? Is she

able to follow through on commitments?

Recognize that a client with PTSD and substance use disorders may have a more difficult

time in treatment. Treatment outcomes for

clients with PTSD and substance use disorders

typically are worse than for other clients with

COD, and worse than for clients with substance

use disorders alone (Ouimette et al. 1998,

1999). Moreover, as compared to clients with

substance use disorders alone, clients whose

substance use disorder co­occurs with PTSD

have more problems in general (e.g., other Axis

I and II disorders, interpersonal and medical

problems, HIV risk) (Brady et al. 1994; Brown

and Wolfe 1994), and their treatment may be

more fragile and prone to relapse, unstable

alliances, and erratic attendance (Root 1989;

Triffleman 1998). If the counselor is to work

effectively with such clients, extra support and

encouragement is needed, along with a positive,

optimistic tone and strong outreach.

Help the client access treatment for PTSD. It is

recognized widely that integrated treatment—

treatment of both PTSD and substance

abuse—is likely to be more successful and more

sensitive to clients’ needs than substance abuse

treatment alone. Yet most clients with PTSD

receive only substance abuse treatment, despite

the fact that they prefer treatment for both

(Brown et al. 1998). The counselor should

inquire whether the client would like to address

her PTSD, and if so, the counselor can play a

pivotal role in providing a referral to such

treatment and the encouragement to participate. To help locate a PTSD specialist, the

International Society for Traumatic Stress

Studies has a listing of members

(http://www.istss.org).

Recognize the importance of one’s own trauma

history. Counselors may have their own histories of trauma, which can have an impact on

their work both for better (increased empathy)

and worse (feeling triggered by clients). Honest

self­evaluation and self­care skills are important, as well as seeking supervision and support

as needed.

Help the client learn to de­escalate intense emotions. The nature of PTSD and substance use is

a frequent experience of overwhelming feelings.

Clients may find a seemingly small comment or

event to be a trigger, which can set off a craving

to use substances. Teaching the client to do

grounding and to soothe himself can be an

important means to regain control. Grounding

(also called “centering,” “looking outward,”

“distraction,” or “healthy detachment”) uses a

set of simple strategies that facilitate detachment from emotional pain, such as drug cravings, self­harm impulses, anger, and sadness.

The technique distracts one from the impulse to

use substances or to hurt oneself by directing

the mental focus outward to the external world,

rather than inward toward the self. Figure D­15

provides a basic overview of what is involved in

grounding. (For a lesson plan and other materials on grounding, see Najavits 2002.)

Strategies, Tools, and

Techniques

It may be difficult for clients with PTSD to

form a trusting therapeutic alliance. They often

have great shame about both their illnesses and

may hide, minimize, or even lie about their

past as a means of psychological self­protection. Particularly in the case of people with

severe PTSD arising from child abuse, distrust

of others and fragile treatment alliances are

common. Clients often are full of anger, which

can be directed at self or at others, including

412 Specific Mental Disorders: Additional Guidance for the Counselor
Figure D­15

Grounding: A Coping Skill for Clients With Emotional Pain

Three major ways of grounding will be described—mental, physical, and soothing. “Mental” means focusing your mind; “physical” means focusing on your senses (e.g., touch, hearing); and “soothing” means talking to yourself in a very kind way. You may find that one type works better for you, or all types may be

helpful. Note that grounding is different from relaxation training or meditation. In grounding, it is essential to keep your eyes open the entire time and to keep talking out loud. These strategies keep you focused

on the outside world.

Mental Grounding

• Describe your environment in detail using all your senses. For example, “The walls are white, there are

five pink chairs, there is a wooden bookshelf against the wall...” Describe objects, sounds, textures, colors, smells, shapes, numbers, and temperature. You can do this anywhere. For example, on the subway:

“I’m on the subway. I’ll see the river soon. Those are the windows. This is the bench. The metal bar is

silver. The subway map has four colors...”

• Play a “categories” game with yourself. Try to name “types of dogs,” “jazz musicians,” “States that begin

with ‘A’,” “cars,” “TV shows,” “writers,” “sports,” “songs,” or “cities.”

• Do an age progression. If you have regressed to a younger age (e.g., 8 years old), you can slowly work

your way back up (e.g., “I’m now 9,” “I’m now 10,” “I’m now 11”...) until you are back to your current

age.

• Describe an everyday activity in great detail. For example, describe a meal that you cook (e.g., “First I

peel the potatoes and cut them into quarters, then I boil the water; I make an herb marinade of oregano,

basil, garlic, and olive oil...”).

• Imagine. Use an image: Glide along on skates away from your pain; change the TV channel to get to a

better show; think of a wall as a buffer between you and your pain.

• Say a safety statement. “My name is ____; I am safe right now. I am in the present, not the past. I am

located in _____; the date is _____.”

• Read something, saying each word to yourself. Or read each letter backward so that you focus on the letters and not on the meaning of words.

• Use humor. Think of something funny to jolt yourself out of your mood.

• Count to 10 or say the alphabet, very s..l..o..w..l..y.

Physical Grounding

• Run cool or warm water over your hands.

• Grab onto your chair as hard as you can.

• Touch various objects around you: a pen, keys, your clothing, the table, the walls. Notice textures, colors, materials, weight, temperature. Compare objects you touch: Is one colder? Lighter?

• Dig your heels into the floor­literally “grounding” them. Notice the tension centered in your heels as you

do this. Remind yourself that you are connected to the ground.

• Carry a grounding object in your pocket—a small object (a small rock, clay, ring, piece of cloth or yarn)

that you can touch whenever you feel triggered.

• Jump up and down.

Specific Mental Disorders: Additional Guidance for the Counselor 413
Figure D­15 (continued)

Grounding: A Coping Skill for Clients With Emotional Pain

• Notice your body: The weight of your body in the chair; wiggling your toes in your socks; the feel of your

back against the chair. You are connected to the world.

• Stretch. Extend your fingers, arms or legs as far as you can; roll your head around.

• Clench and release your fists.

• Walk slowly, noticing each footstep, saying “left” and then “right,” with each step.

• Eat something, describing the flavors in detail to yourself.

• Focus on your breathing, noticing each inhale and exhale. Repeat a pleasant word to yourself on each

inhale (e.g., a favorite color or a soothing word such as “safe” or “easy”).

Soothing Grounding

• Say kind statements, as if you were talking to a small child. For example, “You are a good person going

through a hard time. You’ll get through this.”

• Think of favorites. Think of your favorite color, animal, season, food, time of day, or TV show.

• Picture people you care about (e.g., your children), and look at photographs of them.

• Remember the words to an inspiring song, quotation, or poem that makes you feel better, such as the

Serenity Prayer.

• Remember a safe place. Describe a place that you find very soothing (perhaps the beach or mountains, or

a favorite room); focus on everything about that place—the sounds, colors, shapes, objects, and textures.

• Say a coping statement. “I can handle this.” “This feeling will pass.”

• Plan out a safe treat for yourself, such as a piece of candy, a nice dinner, or a warm bath.

• Think of things you are looking forward to in the next week, perhaps time with a friend, going to a

movie, or going on a hike.

• Create a cassette tape of a grounding message that you can play when needed; consider asking your therapist or someone close to you to record it if you want to hear someone else’s voice.

• Think about why grounding works. Why might it be that by focusing on the external world, you become

more aware of an inner peacefulness? Notice the methods that work for you­—why might those be more

powerful for you than other methods?

• Don’t give up.

counselors. They are likely to engage in power

struggles, especially when they feel helpless.

Counselors must try to maintain professionalism, composure, and empathy in working with

such clients, no matter how difficult. If the

counselor can stay calm, clear, and understand

the relational problems in light of the PTSD,

the client is likely to become engaged. However,

if the clinician argues, gives ultimatums, or

tries to coerce clients, clients are more likely to

drop out of treatment prematurely. Harsh confrontation, particularly for PTSD clients, can

feel like a reexperiencing of childhood trauma

and emotional abuse.

The counselor’s role in reinforcing medications

has been discussed extensively in chapter 5 and

will not be repeated here.

414 Specific Mental Disorders: Additional Guidance for the Counselor
Screening and assessment

It is important to emphasize that, in obtaining

a preliminary diagnosis of PTSD, it can be

damaging to ask the client to describe traumatic events in detail. When screening it is important to limit questioning to very brief and general questions, such as “Have you ever experienced childhood physical abuse? Sexual abuse?

A natural disaster such as a hurricane or tornado? A serious accident? Violence or the

threat of it? Seeing a dead body?” Once a brief

and general identification of such traumas has

occurred, the substance counselor should not

seek to obtain detailed description of such

events, which can be extremely destabilizing

for the client and is unnecessary for screening

purposes. Indeed, it has been found that having

the client complete a written questionnaire leads

to higher reporting of traumas and may be less

upsetting for clients (Najavits et al. 1998).

Assuming the client has a trauma, the Modified

PTSD Symptom Scale (Falsetti et al. 1993) is a

good screening instrument. The scale asks

about each of the DSM­IV symptoms for PTSD

and is useful for monitoring and tracking

PTSD over time. Although it is relatively rare

for clients to become upset when answering a

written questionnaire about trauma, if such a

questionnaire is used, the client should know

how to locate clinical staff for help if the process becomes too upsetting. Both childhood and

adult traumas should be identified; for example, a rape experience within the last year and

early childhood incest both could lead to the

development of anxiety disorders. Because people living in violent situations, such as prostitutes who have been raped, can manifest anxiety symptoms, it is a mistake to ignore proximal

violence and look solely at early traumas. Abuse

of males as well as females must be considered,

as the issue of physical and sexual abuse of

males historically has been overlooked.

Crisis stabilization

Danger to self is a particular risk for clients

with PTSD and substance abuse; the self­harm

may include suicidality, which is common in

this population, as well as self­injurious behavior such as cutting or burning. People in dissociated states may put themselves in danger to

which they remain unaware, thus may require

involuntary commitment. Finally, the potential

for harm to others needs to be considered, particularly in clients with PTSD who show high

levels of aggression and poor impulse control.

The clinician should establish a written plan

that details what the client will do if he feels

the impulse to act out any self­harm behavior;

this plan should include who to call after hours

(for outpatient care), as well as strategies that

may help the client reduce the impulse. The

client and the clinician should each keep a

copy of the plan.

Short­term care and 

treatment

Safety­oriented, skill­building

treatment

For clients with PTSD and substance abuse,

providing psychoeducation about the disorders

and teaching coping skills to gain control over

the symptoms usually form an essential foundation of treatment. For example, the client with

PTSD can learn to identify symptoms of “intrusion, avoidance, and arousal” and be trained to

use grounding to manage these symptoms.

Other skills include rethinking, activity scheduling, seeking out interpersonal support, identifying and fighting PTSD and substance abuse

triggers, and learning to communicate with others. Helping clients understand the link between

their PTSD and substance use is also part of

such treatment; specifically, how each may trigger the other, and how mastery of one disorder

can help with overcoming the other.

Notice that such treatment directly addresses

PTSD but doesn’t push the client to describe

or explore trauma memories. It is considered

the safest and most essential “first­stage”

approach, and is likely the best choice for most

substance abuse treatment settings, particularly those that are short­term, have clients with

PTSD and substance use disorders with acute

suicidality or self­harm, and/or have staff who

Specific Mental Disorders: Additional Guidance for the Counselor 415
have not undergone formal training in PTSD

treatment. For treatment manuals, see

Najavits’ Seeking Safety model (2002), which

has undergone empirical testing, and two manuals in the 12­Step tradition, Evans and

Sullivan (1995) and Trotter (1992).

Trauma exploration work

This type of treatment involves having clients

face their painful trauma memories, telling the

story of what happened, and facing the associated intense emotions. These treatments, all

initially developed on clients who did not abuse

substances, include exposure therapy (Foa and

Rothbaum 1998), mourning (Herman 1997),

eye movement desensitization reprocessing

(Shapiro 1989), and the counting method

(Ochberg 1996). Such treatments are considered high­risk for substance abuse clients and

should be conducted (or at least supervised)

only by providers with formal training in

PTSD, and then only when the client is ready.

Readiness for such work depends on a variety

of factors, including the context of treatment

(i.e., length of stay), the client’s safety level,

and the availability of staff to manage the

intense feelings that surface (often after hours).

As noted above, even if the client wants to talk

about trauma, he or she may not be ready to

do so safely and may underestimate the destabilizing effect such work will have.

Only a few pilot studies so far have evaluated

trauma­exploration therapies in substance

abuse clients (Brady et al. 2001; Triffleman

2000). While some positive results have been

found, generally it is believed that more work is

needed to define which clients, under what conditions, and with what staff training, are needed for this type of work.

Longer term care

For clients with a severe trauma history, treatment is likely to be long term. If possible, refer

the client with PTSD to an individual therapist

who can work with the client consistently over

a long period. Individual therapy generally is

needed (in addition to the standard group

treatments typical of substance abuse treatment programs) to permit confidential discussion of, and adequate attention to, trauma.

Case Study: Counseling a Client with Polysubstance Abuse

and PTSD

Carlos F. is a 34­year­old man who repeatedly has been admitted to detoxification and substance abuse

treatment for polysubstance abuse. He appears aggressive and defensive and tends to isolate. Since childhood, he has a long history of starting fights, and does not like to talk about his past. He was not assessed

for PTSD until the present admission, where a counselor found out that he was physically and sexually

abused by his mother during childhood. Carlos F. had never heard of PTSD, but when presented with education about the symptoms he was able to recognize them in himself immediately. Carlos F. stated, “I always

thought there was just something wrong with me—bad genes, or just a bad attitude. It is a relief to know

there’s a reason why I feel and act the way I do.”

Discussion: Counselors often are more likely to diagnose PTSD in women, with the single exception being

soldiers or survivors of kidnapping or torture. It is important to screen for PTSD for all clients—men and

women—and for all types of trauma. For more information on PTSD and trauma, see the forthcoming TIP

Substance Abuse Treatment and Trauma (CSAT in development d).

416 Specific Mental Disorders: Additional Guidance for the Counselor
Eating Disorders

Description

Dieting and concern about body weight and

shape are ever­present among people (especially women) in Western cultures. Young women

who are of normal weight report high rates of

dissatisfaction with their body weight and size.

Dieting, which is nearly universal among

female youth, often is the first step toward

developing an eating disorder; however, only a

small percentage of women who diet actually

progress to an eating disorder. The primary

eating disorders are anorexia nervosa and

bulimia nervosa; however, the classification

system has not yet been perfected, as the

majority of individuals who seek treatment for

an eating disorder fall under the diagnostic

heading of “eating disorders not otherwise

specified.”

Anorexia nervosa

Anorexia nervosa, the most visible eating disorder, is marked by a refusal to maintain body

weight above the minimally normal weight for

age and height (currently operationalized as 85

percent of expected weight for height).

Anorexia nervosa (“nervous loss of appetite”)

is a misnomer. Only in extreme stages of inanition (i.e., exhaustion as a result of lack of

nutrients in the blood) is appetite actually lost.

Individuals with anorexia nervosa have a

dogged determination to lose weight and can

achieve this in several ways. Individuals with

the classic restricting subtype of anorexia nervosa achieve this weight loss solely through

severe food restriction, exercise, and fasting.

Others augment their dieting with vomiting,

laxative use, diuretic use, diet pills, and other

methods of purging. In addition to these purging behaviors, women with the bulimic subtype

also exhibit binge eating.

Individuals with anorexia nervosa have an

intense fear of gaining weight even when emaciated, place undue importance on weight and

shape in terms of self­evaluation, deny the seriousness of their illness, and may experience a

distortion of the manner in which they perceive

their own body size (i.e., they may see themselves as fat even when emaciated). In women,

the cessation of menstrual periods for 3 or

more months officially is required to diagnose

anorexia nervosa; however, this criterion

should be viewed with caution because there is

great variation in the reproductive system’s

response to starvation.

The age of onset of anorexia nervosa usually is

during the teenage years (Lucas et al. 1991).

However, it can occur earlier and may emerge

at any time.

Bulimia nervosa

The core symptoms of bulimia nervosa are

bingeing and purging. A binge is regarded as

the rapid consumption of an unusually large

amount of food by comparison with social

“norms” in a discrete period of time. Integral

to the notion of a binge is feeling out of control.

An individual with bulimia may state that he or

she is unable to postpone the binge or stop eating willfully once the binge has begun. The

binge may only end when she is interrupted,

out of food, exhausted, or physically unable to

consume more. Although the current DSM­IV

diagnostic criteria require the presence of binge

eating at least twice per week for at least 3

months (see chapter 8), bingeing and purging

clearly are unhealthy behaviors and should not

be ignored when present at lesser frequencies.

The second feature of bulimia nervosa is purging. There are many different ways that individuals with bulimia nervosa compensate for

overeating. Between 81 and 88 percent of

women with bulimia self­induce vomiting (Hoek

and van Hoeken 2003; Johnson et al. 1982;

Mitchell et al. 1985; Rome 2003; Sigman 2003).

Other methods of purgation include the abuse

of laxatives, diuretics and emetics, saunas,

excessive exercise, fasting, and other idiosyncratic methods that people believe will lead to

weight loss. Many of these auxiliary methods

are dangerous and ineffective as they promote

loss of water and valuable electrolytes (see the

Specific Mental Disorders: Additional Guidance for the Counselor 417
section on crisis stabilization below). Finally,

individuals with bulimia nervosa place undue

emphasis on shape and weight in their sense of

identity.

The age of onset of bulimia nervosa is generally

somewhat later than for anorexia nervosa;

however, many women have bulimia for up to 5

years prior to seeking treatment.

Other eating disorders

There are several alternative and subthreshold

presentations of disordered eating. Among

these are individuals who purge in the absence

of binge eating, as well as individuals who meet

some but not all formal diagnostic criteria for

anorexia or bulimia nervosa. Binge­Eating

Disorder (BED) is being scrutinized as a potential third discrete eating disorder. BED is associated with binge eating in the absence of compensatory behaviors and commonly is associated with obesity.

Prevalence

Anorexia nervosa primarily is a disorder of

females, with a gender ratio of approximately

10:1. The disorder is found across social classes

and ethnic groups. Epidemiological studies suggest a prevalence of between 0.1 to 0.7 percent

of females, although subclinical conditions are

more prevalent (Hoek 1991; Hoek and van

Hoeken 2003; Rome 2003; Sigman 2003).

Anorexia nervosa is more prevalent in sports

and professions that value thinness (e.g., jockeys, ballet dancers, gymnasts). Males who

develop the disorder have presenting symptoms

and clinical profiles similar to females.

The gender ratio for bulimia nervosa is also

approximately 10:1, with higher prevalence in

females. Epidemiological studies suggest that

the prevalence of bulimia nervosa is somewhere

between 1 and 3 percent across a range of

Western cultures (Bushnell et al. 1990;

Drewnowski et al. 1988; Garfinkel et al. 1995;

Johnson­Sabine et al. 1988; Kendler et al.

1991; King 1986; Rand and Kuldau 1992;

Schotte and Stunkard 1987). Again, subclinical

forms of the disorder are more prevalent.

Bulimia is found across all ethnic groups and

social classes. Indeed, recent epidemiological

evidence suggests that binge eating may be

becoming more common in the lower socioeconomic classes and that the gender disparity

may be diminishing.

Substance abuse and 

dependence among people

with eating disorders

Estimates of the prevalence of co­occurring

substance abuse and/or dependence in clinical

samples of women with bulimia nervosa have

varied widely. The prevalence of comorbid substance abuse ranges between 3 percent and 49

percent. A review of 25 studies of the prevalence of substance abuse in women with bulimia

nervosa in clinical samples calculated a median

prevalence of 23 percent (Corcos et al. 2001;

Holderness et al. 1994; Specker and

Westermeyer 2000; Westermeyer and Specker

1999). Parameters affecting the estimates differ

according to the nature of the clinical service

(inpatient versus outpatient), the definition of

the disorder, assessment procedures for both

eating disorders and substance dependence,

whether current or lifetime diagnoses are

assessed, the distorting effects of any exclusion

criteria for clinical trials, and the age of clients

seen.

Overall, the majority of studies have observed

an elevated prevalence of substance abuse in

clinical samples of women with bulimia nervosa. Most studies have observed comorbidity

that exceeds that expected in the general population of women of similar age, as well as higher

rates than in women with major depression.

Population­based studies also have observed

elevated substance abuse in women with bulimia nervosa (although not as extreme as in clinical samples), suggesting that the observed cooccurrence is not merely the result of focusing

studies on treatment­seeking populations.

The frequently observed co­occurrence of substance abuse in women with bulimia nervosa

418 Specific Mental Disorders: Additional Guidance for the Counselor
warrants routine screening for the presence of

substance abuse when women with bulimia nervosa are assessed. The screening ideally would

address both current and lifetime presence of

alcohol and other substance use disorders and

would seek to develop an indepth understanding of the relation between the eating disorder

and substance use.

Substance abuse appears to be much less frequent in women with the restricting subtype of

anorexia nervosa than in other subtypes of eating disorders (Corcos et al. 2001; Specker and

Westermeyer 2000; Westermeyer and Specker

1999). In most studies, the prevalence of substance abuse in women with anorexia nervosa

was less than in women with bulimia nervosa

and not significantly different from women in

the general population. Substance use disorders are observed primarily in women with the

bulimic subtype of anorexia. Across studies,

the prevalence of substance­related disorders

in anorectic women with bulimic features

appear to be comparable to or exceed those of

women with normal weight bulimia nervosa

(Corcos et al. 2001; Specker and Westermeyer

2000; Westermeyer and Specker 1999).

In summarizing the data regarding the prevalence of substance abuse in clinical samples of

women with eating disorders, several issues

must be considered. First, although the prevalence of comorbid substance abuse is high, it is

not the most frequently diagnosed comorbid

condition. Most studies have reported more

frequent lifetime comorbid affective and anxiety disorders. Thus, comorbidity of a range of

disorders, not just substance abuse, commonly

is observed in women with bulimia nervosa.

In addition, with some exceptions, most studies

have been cross­sectional and have determined

the eating disorder diagnosis based on current

clinical presentation. This approach is conceptually problematic as the boundary between

anorexia and bulimia nervosa often is fluid.

Although a percentage of women with the

restricting subtype of anorexia never binge or

purge, between 37 and 48 percent of clinical

samples of women with anorexia nervosa display features of

bulimia nervosa at

some point during

their illness. The distinction between current anorexia nervosa

with or without current bulimic symptoms has been codified in the DSM­IV

into “restricting” and

“binge­eating/purging” types. It is difficult, if not impossible,

to predict accurately

which women are

likely to recover,

maintain a chronic

course of restricting

anorexia, or develop

bulimia nervosa. Therefore, when examining

the prevalence of substance abuse in women

with eating disorders, counselors must be

mindful that the clinical features on which

groups are defined are multifaceted, and that a

cross­sectional examination of the same sample

at a later date may yield different groupings,

and therefore, different estimates of the prevalence of comorbidity.

Eating disorders

and disordered eating appear to be

overrepresented in

clinical samples of

women presenting

for treatment of

substance abuse.

Eating disorders among 

individuals with substance

use disorders

To what extent are eating disorders a problem

in individuals with primary substance use disorders? Studies examining prevalence of eating

disorders in substance­dependent treatment

samples have used both questionnaires and

interview designs. With some exceptions, the

prevalence of bulimia nervosa is elevated in

women presenting for treatment of substance

dependence (Corcos et al. 2001; Specker and

Westermeyer 2000; Westermeyer and Specker

1999). The characteristics of people with substance use disorders and bulimia included

younger age at presentation, onset of problem

drinking at an earlier age, higher self­report

scores on eating pathology, decreased chance of

Specific Mental Disorders: Additional Guidance for the Counselor 419
a family history of alcoholism, and heavier

weight.

A study of callers to a national cocaine hotline

(122 men and 137 women) via a structured telephone interview found that 22 percent of

callers met DSM­III criteria for bulimia, 7 percent for anorexia and bulimia, 2 percent

anorexia nervosa, and 9 percent met criteria

for bulimia plus vomiting. Among female

callers, 23 percent met criteria for bulimia and

13 percent met criteria for bulimia with purging (Jonas et al. 1987).

Studies of individuals in inpatient substance

abuse treatment centers suggest that approximately 15 percent of women and 1 percent of

men had a DSM­III­R eating disorder (primarily bulimia nervosa) in their lifetime as assessed

via questionnaire (Hudson et al. 1992).

Individuals with eating disorders were significantly more likely to use stimulants and significantly less likely to use opioids than individuals

undergoing substance abuse treatment without

comorbid eating disorders.

In summary, eating disorders and disordered

eating appear to be overrepresented in clinical

samples of women presenting for treatment of

substance abuse. Further studies are required

to assess how the presence of an eating disorder

affects treatment for substance abuse and how

best to integrate treatment for those with both

conditions.

Substance Use Among

Individuals With Eating

Disorders

Studies of bulimic women with co­occurring

alcohol use disorders often have used retrospective interviews to determine the chronology

of the onset of both disorders. Patterns vary,

with approximately one third of women recalling bulimia beginning first, one third recalling

the alcohol abuse beginning first, and one third

recalling onset of both problems within the

same year (Bulik et al. 1997).

Several investigations have found no differences in the core clinical features of bulimia

nervosa (i.e., frequency of bingeing and purging) in women with and without co­occurring

substance use disorders (Bulik et al. 1997),

although those with comorbid substance use

disorders showed greater use of diuretics and

laxatives, more food restriction, greater disruption in financial and work areas, more stealing,

more suicide attempts, and more inpatient

treatment (Hatsukami et al. 1986).

Personality differences also appear to exist

between bulimic women with and without substance use disorders. Women with bulimia nervosa and substance dependence also report

higher novelty seeking and lower cooperativeness, higher impulsivity, and a tendency to use

more immature defenses. Overall, women with

bulimia nervosa and alcohol dependence exhibited a pattern of greater impulsiveness across a

broad array of response domains (Bulik et al.

1997).

The subgroup of women with bulimia who

exhibit these traits have been referred to as

“multi­impulsive bulimics,” defined as a combination of bulimia plus other impulsive behaviors such as excessive alcohol use, regular

street drug use, stealing, overdosing, self­harm,

borderline features, and sexual promiscuity

(Lacey 1993). Approximately 40 percent of

bulimic women seen in clinical settings display

substance abuse, stealing, overdosing, or selfharm (Lacey 1993). This group of individuals

requires higher clinical vigilance and is at higher risk for self­harming and parasuicidal

behaviors.

In summary, the core clinical features of the

eating disorder (i.e., frequency of bingeing and

purging) do not appear to differ significantly

whether substance abuse or dependence is present. Individuals with the comorbid pattern do

appear to display more frequent impulsive

behaviors, use of other drugs, and possibly

more Axis II pathology. These data suggest that

it is important to consider the critical role of

impulsivity in the development of both eating

420 Specific Mental Disorders: Additional Guidance for the Counselor
disorders and substance abuse in this group of

women. See Figure D­16 for a summary of how

eating and substance use disorders are related.

Key Issues and Concerns

In addition to “traditional” drugs of abuse and

alcohol, women with eating disorders are

unique in their abuse of pharmacological

agents ingested for the purpose of weight loss,

appetite suppression, and purging. Among

these drugs are prescription and over­thecounter diet pills, laxatives, diuretics, and

emetics. Nicotine and caffeine also must be

considered when assessing substance abuse in

women with eating disorders.

Drugs related to purging, such as diuretics, laxatives, and emetics, have been shown to be

ineffective and potentially dangerous methods

of accomplishing weight loss or maintenance.

The literature suggests that, like more common

drugs of abuse, tolerance and withdrawal occur

with laxatives, diuretics, and possibly diet pills

and emetics.

A critical message for clinicians is that women

with eating disorders often will go to dangerous

extremes to lose weight and a comprehensive

assessment must document the individual’s full

repertoire of weight­loss behaviors. Clinicians

also must be mindful of excessive consumption

of sugar substitutes, as the long­term effect of

consumption of large quantities of these substances in humans is yet to be determined.

Strategies, Tools, and

Techniques

Though the presence of a history of alcohol

abuse or dependence appears not to affect outcome in trials of cognitive–behavioral or pharmacological therapy for bulimia nervosa, much

less is known regarding the effects of current

substance use on treatment outcome for bulimia nervosa. Practically, the management of

individuals with concurrent active bulimia and

substance abuse can be challenging. Given that

few treatment programs specialize in the treatment of concurrent eating and substance abuse

problems, the phenomenon of treatment pingpong often is observed. Individuals may alternate between eating disorders and substance

abuse treatment programs without ever benefiting from treatment that targets both problems

simultaneously.

Figure D­16

How Are Eating Disorders and Substance Use Disorders Related?

• Individuals with eating disorders experience urges (or cravings) for binge­foods similar to urges for drug

or alcohol use.

• Many individuals alternate between substance abuse and eating disorders.

• Bingeing and purging can be secretive and shameful behaviors.

• Relapse prevention is critical for individuals with bulimia nervosa.

• Abstinence from bingeing and purging is an essential treatment goal.

• For individuals with bulimia nervosa, alcohol and drugs such as marijuana can diminish normal appetite

restraints and increase the risk of binge­eating as well as relapse.

• Individuals with eating disorders experience cravings, tolerance, and withdrawal from drugs associated

with purging, such as laxatives and diuretics.

• There is an increased risk of alcohol and drug abuse and dependence in family members of individuals

with bulimia nervosa.

Specific Mental Disorders: Additional Guidance for the Counselor 421
Engagement

No controlled trials have yet been conducted to

determine the optimal intervention strategy for

women with co­occurring eating disorders and

substance use disorders, although a variety of

treatments have been described (Bergh et al.

2003; McElroy et al. 2003; Trotzky 2002;

Weiner 1998). Few specialist services exist that

are designed to treat eating disorders and substance abuse concurrently. In the absence of

such services, staff on specialty services for

substance use or eating disorders should have

specific training in working with individuals

with this particular pattern of comorbidity.

Even less is known about men with eating disorders, and almost nothing has been written

recently about their treatment (Mangweth et al.

2004).

Screening and assessment

Even though a client may not have an eating

disorder currently, the past presence of bulimia

or anorexia could become a factor in the successful treatment of her substance abuse, or

vice versa. To detect this possibility, clinical

interviews may be supplemented with structured eating disorders interviews such as the

Eating Disorders Examination. A number of

medical investigations might be warranted,

depending on the findings on physical examination and based on the nature and severity of

the substance­related disorder.

Figure D­17 suggests general and specific

screening questions that may be used to probe

the possibility that the client has an eating disorder. The general questions simply explore the

individual’s attitudes toward shape, weight,

and dieting. Sometimes it is best to start with

such questions rather than begin immediately

with questions focused specifically on the

behavior patterns associated with anorexia and

bulimia because clients may feel shame about

these behaviors. Easing into the topic sometimes is the best approach.

Once the co­occurrence of eating and substance

use disorders has been established, then a complete behavioral analysis can be informative, if

consistent with the philosophy and approach of

the treatment service. The critical questions to

be addressed in this portion of the assessment

include foods and substances of choice, highrisk times and situations for engaging in disorFigure D­17

General and Specific Screening Questions for Persons With Possible

Eating Disorders

General Screening Questions

•How satisfied are you with your weight and shape?

•How often do you try to lose or gain weight?

•How often have you been dieting?

•What other sorts of methods do you use to lose weight?

Specific Screening Questions

•Have you ever lost a lot of weight and weighed less than other people thought you should weigh?

•Have you had eating binges where you eat a large amount of food in a short period of time?

•Do you ever feel out of control when eating?

•Have you ever vomited to lose weight or to get rid of food that you have eaten?

•What other sorts of methods have you used to lose weight or to get rid of food?

422 Specific Mental Disorders: Additional Guidance for the Counselor
dered eating and substance abuse behaviors,

and the nature, pattern, and relationship of

disordered eating and substance use. Examples

of appropriate areas of inquiry are

• What sorts of situations could prompt the

client to diet/binge/drink?

• What times of the day are high­risk times for

each behavior?

• What are the cues that prompt disordered

eating behavior/substance use?

In addition, counselors must address how dieting and bingeing are related to substance

abuse. For example, does the client drink or

use drugs to curb appetite when dieting? What

is the effect of drinking on eating behavior?

Does alcohol use lead to unrestrained eating?

From the client’s perspective, do bingeing and

drinking serve similar or different “functions?”

Crisis stabilization

Crisis situations differ somewhat between

women with anorexia and bulimia nervosa. In

both cases, the presence of substance abuse

intensifies the crisis. Presenting symptoms

include dehydration, electrolyte abnormalities,

cardiac or gastrointestinal complications, secondary to extreme inanition, and suicidality.

Women with bulimia nervosa may present in

crisis with dehydration, electrolyte abnormalities, gastrointestinal crises secondary to purging (e.g., esophageal ruptures or instruments

used for purging lodged in the throat), or suicidality.

In the case of both disorders, medical stabilization is of primary importance. Anorexia nervosa, in particular, is the most lethal of all

mental disorders, with a mortality rate of

approximately 6 percent per decade (Sullivan

1995). Deaths associated with anorexia nervosa

are most commonly complications of starvation

followed closely by suicide. Hospital admission

with vigilant monitoring for disordered eating

behaviors (e.g. bingeing, purging, excessive

exercising) is critical. In their terror of weight

gain, clients might attempt to engage in disordered eating behaviors in the hospital and

sneak substances such as laxatives and diuretics into treatment facilities.

Short­term care and 

treatment

Once a diagnosis has been established and the

behavioral parameters identified, three potential approaches have been outlined for the

treatment of the individual with eating disorders and substance abuse. First, both disorders

can be treated concomitantly on a unit specializing in this particular pattern of COD.

Second, detoxification and treatment for substance abuse can be completed first, followed

by specialized treatment for the eating disorder. Third, specialized treatment for the eating

disorder can be followed by specialized treatment for the substance abuse.

There are several factors that can dictate

which of these approaches is followed; however, no empirical data exist to inform the decision. Specialty services for clients with COD

are scarce and hence the opportunity for concurrent treatment is limited. In the absence of

such a service, counselors must attempt to

determine which disorder currently is most

troublesome and requires the most immediate

attention. Perhaps the most important treatment goal is to encourage the client to complete

treatment for both disorders, although detoxification is an essential first step for some individuals. Completion should be emphasized

throughout the treatment process.

Whichever treatment approach is chosen, the

other disorder cannot be compartmentalized

and ignored. It is critical to address the presence of the eating problem, even if the substance­related problem is the initial target of

treatment. Failure to integrate treatment leads

to the “ping­pong” phenomenon where clients

bounce back and forth between eating and substance abuse treatment services, never addressing the relation between the two disorders. The

re­emergence of binge eating following detoxification from opioids and alcohol has been

observed. It has also been noted clinically that

the frequent behavioral pairing between disorSpecific Mental Disorders: Additional Guidance for the Counselor 423
dered eating behaviors and substance abuse

can lead to a situation in which relapse in one

domain fuels relapse in the other. Thus, an

integrated relapse prevention plan that

acknowledges the similarities and differences in

relapse risk for each behavior is essential.

Individuals with eating disorders who are being

treated in substance abuse treatment facilities

should participate fully in the substance abuse

treatment program. Their treatment may be

augmented with nutritional consultation, the

setting of a weight range goal, and observations

at and between meal times for disordered eating behaviors. If a treatment program has sufficient numbers of clients who have eating disorders or disordered eating behavior, special

eating disorders psychoeducation or basic cognitive–behavioral strategy groups can be used

to augment the substance abuse treatment

plan.

The available literature supports the inclusion

of clients with past or current mild or moderate

substance­related disorders in eating disorders

treatment programs. Cognitive–behavioral

techniques targeted toward bulimic symptoms

such as psychoeducation, identification of automatic thoughts, thought restructuring, chaining, and relapse prevention, often generalize to

substance­related problems.

Treatment of individuals with severe substancerelated disorders and eating disorders poses a

more significant clinical challenge. In addition

to traditional cognitive–behavioral approaches,

many individuals find 12­Step approaches beneficial in controlling their drinking or drug use

and disordered eating behavior. Traditionally,

the 12­Step approach of Overeaters

Anonymous focuses on abstinence from highrisk foods (i.e., sugar, wheat), which are

believed to have the ability to trigger a binge.

In direct contrast, the cognitive–behavioral

approach emphasizes empowerment over food

and minimizes avoidance.

Although it is possible to abstain from alcohol

and drugs, it is virtually impossible to abstain

from foods, given their obvious relationship to

survival and the frequency with which highrisk foods are encountered in daily life. In an

integrated model that tries to merge

cognitive–behavioral techniques with the beneficial 12­Step approach, one can encourage

clients to abstain from high­risk behaviors (i.e.,

dieting or bingeing) rather than high­risk

foods. Empirical data are required to substantiate the efficacy of this approach; however, it

holds intuitive appeal for those individuals who

find a 12­Step approach beneficial and who see

similarities between their disordered eating and

substance­related problems.

Pharmacological approaches to treatment also

may be considered. The SSRI fluoxetine has

been shown to be of some efficacy in the treatment of bulimia nervosa (Fluoxetine Bulimia

Nervosa Collaborative Study Group 1992),

although its specific efficacy in individuals with

comorbid substance use disorders has not been

documented. The opioid antagonist naltrexone

appears to decrease the reinforcing efficacy of

alcohol and has been approved by the Food

and Drug Administration for the treatment of

alcohol dependence because of its efficacy in

reducing alcoholic relapse. Preliminary data

suggest that naltrexone may decrease the frequency of bingeing and purging and the preoccupation with food in women with bulimia

(Jonas and Gold 1988). The possible utility of

naltrexone in the treatment of individuals with

comorbid bulimia nervosa and alcohol dependence is an empirical question worthy of further investigation.

No clinical trials exist that identify the optimal

approach to the treatment of comorbid eating

disorders and substance­related disorders.

Such trials clearly are needed to determine the

most effective approach to individuals who present with severe co­occurring eating and substance­related disorders.

Longer term care and 

treatment

Relapse is a major concern in eating disorders.

Anorexia nervosa is particularly difficult to

treat, with the average duration of treatment

being 5 years. Even women who have recov424 Specific Mental Disorders: Additional Guidance for the Counselor
ered from anorexia nervosa continue to maintain relatively low body weight and retain cognitive features of the disorder.

Although relatively successful treatments for

bulimia nervosa have been developed (primarily cognitive–behavioral therapy), which lead to

abstinence in between half and two thirds of

clients, relapse is common within the first year

following therapy. Thus, concrete relapse prevention strategies are critical both to prevent

the re­emergence of disordered eating symptoms as well as to prevent the ping­pong effect

in symptom expression. Techniques that can be

incorporated into a successful relapse prevention program include

• Booster therapy sessions

• Participation in both 12­Step groups and

more unstructured support groups for eating

disorders and for substance abuse

• Use of self­help manuals and programs when

slips occur and regularly throughout the

recovery intervals

• Development of strategies that enhance selfawareness of imminent slips and relapses

Pathological Gambling

Description

Pathological gambling (PG) has been best

described as “a progressive disorder characterized by a continuous or periodic loss of control

over gambling; a preoccupation with gambling

or obtaining money with which to gamble; irrational thinking, and a continuation of the

behavior despite adverse consequences”

(Rosenthal 1992). The American Psychiatric

Association’s criteria for the diagnosis of PG

(DSM­IV­TR) (APA 2000) are in many ways

similar to those for alcohol and other drug

dependence (see Figure D­18, p. 426).

Many clients with PG display what amounts to

tolerance, needing to gamble with increasing

amounts of money (or make increasingly risky

bets with what money is available to them) to

achieve the desired effect. For some gamblers,

often referred to as “action” gamblers, this

effect may be excitement (Cocco et al. 1995;

Lesieur and Rosenthal 1991). For other gamblers, thought of as “escape” gamblers, the

sought­for effect is relief from painful emotions

or stress. Consequently, gambling may act as a

stimulant such as amphetamine or cocaine for

some clients with PG, while acting as a sedative

or tranquilizer for others. (See Figure D­19 on

p. 427 for a list of differences between action

and escape gamblers.)

Pathological gamblers often report withdrawallike symptoms when attempting to stop gambling. These may include symptoms such as

irritability, problems focusing or concentrating,

difficulty sleeping, and even physical symptoms

such as nausea, vomiting, headaches, and muscular pain (Rosenthal and Lesieur 1992; Wray

and Dickerson 1981). Currently, there are no

DSM criteria for gambling disorders that compare directly to criteria for substance use disorders. However, in practice, the term “problem gambling” is most commonly considered to

apply to those individuals who meet one to four

of the DSM­IV criteria for pathological gambling (National Research Council [NRC] 1999).

Problem gamblers are individuals who do not

meet full criteria to be diagnosed as pathological gamblers, but who meet some of the criteria

and indicate that gambling is contributing to

some level of disruption in their lives.

While there are similarities between PG and

substance use disorders, there are some significant differences between these disorders.

Research comparing individuals diagnosed with

PG to individuals with substance use disorders

is still in early stages, but there have been clinical reports on such differences. To begin with,

it may be more difficult to define what constitutes gambling than to define a drug or an alcoholic drink. Gambling can encompass a variety

of behaviors: buying lottery tickets, playing

cards for money (even in friendly family

games), investing in the stock market, participating in a charity raffle, betting on a golf

game, betting on horse races, or playing

scratch­off games to win money at a fast food

restaurant.

Specific Mental Disorders: Additional Guidance for the Counselor 425
Figure D­18

Diagnostic Criteria for Pathological Gambling Compared to Substance

Dependence Criteria

Source: APA 2000.

Diagnostic Criteria for Pathological Gambling Comparable Substance Dependence Criteria

Persistent and recurrent maladaptive gambling

behavior as indicated by five (or more) of the following:

Maladaptive pattern of substance use, leading to clinically significant impairment of distress, as manifested by

three (or more) of the following, occurring at any time in

the same 12­month period:

• Is preoccupied with gambling (e.g., preoccupied

with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble)

• A great deal of time is spent in activities necessary to

obtain the substance (e.g., visiting multiple doctors or

driving long distances), use the substance (e.g., chain

smoking), or recover from its effects

• Needs to gamble with increasing amounts of

money to achieve the desired excitement

• Tolerance

• Has repeated unsuccessful efforts to control, cut

back, or stop gambling

• There is a persistent desire or unsuccessful efforts to cut

down or control substance use

• Is restless or irritable when attempting to cut

down or stop gambling

• Withdrawal

• Gambles as a way of escaping from problems or

of relieving a dysphoric mood (e.g., feelings of

helplessness, guilt, anxiety, depression)

• N/A

• After losing money gambling, often returns

another day to get even (“chasing” one’s losses)

• The substance is often taken in larger amounts or over a

longer period than was intended

• Lies to family members, therapist, or others to

conceal the extent of involvement with gambling

• The substance use is continued despite knowledge of

having persistent or recurrent physical or psychological

problem that is likely to have been caused or exacerbat­

• Has committed illegal acts such as forgery, ed by the substance

fraud, theft, or embezzlement to finance gambling

• Relies on others to provide money to relieve a

desperate financial situation caused by gambling

• Has jeopardized or lost a significant relationship, job, or educational or career opportunity

because of gambling

• Important social, occupational, or recreational activities

are given up or reduced because of substance use

426 Specific Mental Disorders: Additional Guidance for the Counselor
Figure D­19

Comparison of Action and Escape Pathological Gamblers

Action Escape

•

•

•

•

•

•

Gambles for excitement, competition

More likely to engage in “skilled” forms of gambling such as poker, horse racing, sports

More likely to have early onset of gambling

Longer progression from regular gambling to

addictive/out of control gambling

More likely to be male

More likely to present narcissistic or antisocial

traits

•

•

•

•

•

•

Gambles for relief, escape from stress or negative affect

More likely to engage in “luck” forms of gambling such

as lottery, slots, video poker, bingo

Later onset of gambling

Shorter progression from regular gambling to

addictive/out of control gambling

More likely to be female

More likely to be dysthymic

One of the main differences between PG and

substance use disorders is that there is no biological test to screen for PG. The absence of a

clear physical sign of the disorder enables a

person to hide gambling behavior for longer

periods of time. This also may contribute to the

severe and entrenched lying and deception that

are included in the diagnostic criteria for PG.

Because no substance is being ingested, often it

is very difficult for individuals diagnosed with

PG and their families/significant others to

accept PG as a medical disorder. Research is

beginning to establish a biological/genetic predisposition to PG that is similar to that found

in severe alcohol and drug addictions, and that

gambling may affect the central nervous system

in ways similar to substance use (Breiter et al.

2001; Comings et al. 1996; Potenza 2001;

Slutske et al. 2000). However, it is still difficult

for individuals with PG, as well as the general

public, to accept a medical model for this disorder. It is easier to accept that people with substance use disorders may behave badly (become

aggressive or violent) while intoxicated than for

gamblers to accept that their harmful behavior

can be attributed to their gambling. This possibility could exacerbate the gambler’s sense of

shame and guilt and contribute to the development of rigid defense mechanisms to ward off

these feelings and to allow gambling to persist.

These hypothesized differences need to be

investigated empirically.

Prevalence

Legalized gambling is available in 47 States and

the District of Columbia. The great majority of

adults (81 percent) have gambled sometime

during their life. This compares to recent studies of alcohol use in the United States that estimate 91 percent of adults have drunk alcohol.

Between 1974 and 1995, the amount of money

spent on legal gambling increased 3,100 percent

in the United States, from $17.4 billion to $550

billion. A national study estimated the lifetime

prevalence of pathological gambling among

adults in the United States to be 1.1 percent,

while the past­year estimate for problem or

pathological gambling combined was 2.9 percent. This can be compared to past­year estimates of alcohol abuse/dependence of 9.7 percent and drug abuse/dependence of 3.6 percent

(NRC 1999).

Information on the prevalence of pathological

gambling among adolescents has been controversial, with reported rates higher than for

adults (Shaffer et al. 1997). However, adolescent rates of problem or pathological gambling,

Specific Mental Disorders: Additional Guidance for the Counselor 427
which range from 9 to 23 percent in various

studies, are comparable to rates of adolescent

alcohol use (8 to 23 percent). Also, past­year

adolescent pathological gambling rates of 1 to 6

percent are comparable to past­month rates of

marijuana use of 3 to 9 percent (NRC 1999).

Gambling prevalence studies also illuminate

demographic variables and risk for gambling

problems. As suggested above, younger age

seems to be a risk factor. Adults under the age

of 30 report higher proportions of gambling

problems. Men, ethnic minorities, and paradoxically, those with household incomes below

$25,000 also tend to be overrepresented among

problem/pathological gamblers. Employment

status did not seem to have any relationship to

risk for gambling problems. However, educational level had a moderate relationship with

problem gambling, with those with a high

school education or less being at higher risk for

gambling problems (NRC 1999).

The rate of co­occurrence of PG among people

with substance use disorders has been reported

as ranging from 9 to 16 percent (Crockford and

el­Guebaly 1998; Lesieur et al. 1986;

McCormick 1993). Among pathological gamblers, alcohol has been found to be the most

common substance of abuse. At a minimum,

the rate of problem

gambling among

people with substance use disorders

is 4 to 5 times that

found in the general

population.

People with substance use disorders

and co­occurring

PG have been compared to people with

substance use disorders without PG.

While some findings

appear contradictory, there is some evidence that people

with co­occurring

substance use and PG may have higher levels

of negative affect, overall psychiatric distress,

impulsivity, higher rates of antisocial personality disorder, AD/HD, and risky sexual behaviors (APA 2000; Crockford and el­Guebaly

1998; Langenbucher et al. 2001; McCormick

1993; Petry 2000b, c). The high rates of cooccurrence of substance use disorders and

gambling problems clearly emphasize the need

for screening and assessment of gambling problems in substance­abusing populations.

In individuals

with COD, it is

particularly

important to

evaluate patterns

of substance use

and gambling.	 

Key Issues and Concerns

Despite the high prevalence, treatment services

for PG are limited or lacking in many areas.

According to a survey conducted by the

National Council on Problem Gambling, only

21 States provide some level of funding for

addressing problem and pathological gambling.

According to the Association of Problem

Gambling Service Administrators, only 16

States provide some public funding specifically

for gambling treatment. Additionally, only

about 1,000 Gamblers Anonymous meetings are

held in the United States, fewer than the number of AA meetings found in some major

metropolitan areas.

It is important to recognize that even though

PG often is viewed as an addictive disorder,

clinicians cannot assume that their knowledge

or experience in substance abuse treatment

qualifies them to treat persons with a PG problem. Training and supervision should be

obtained to work with pathological gamblers,

or referral should be made to specific gambling

treatment programs.

A second consideration is that clients with PG

problems seeking treatment have high rates of

legal problems. Research has shown that in

most settings, two thirds of people with PG

problems report engaging in illegal activities to

obtain money for gambling or to repay gambling

debts. Pathological gamblers often fail to report

such activities as embezzling from their job as

an illegal activity. In their own minds they label

what they are doing as borrowing rather than

428 Specific Mental Disorders: Additional Guidance for the Counselor
stealing, as they are certain that they will make

a winning bet and be able to pay the money

back. Persons with substance use disorders also

have many of these same problems.

Transference and countertransference issues in

the treatment of pathological gambling can have

a significant impact. Competitive, action­oriented gamblers may attempt to make treatment a

competitive sport, and clinicians may become

distracted by debating and arguing. Relapsing

may become a way for the pathological gambler

to “beat” the therapist. The lack of physical

signs or biological tests for gambling can contribute to countertransference reactions, such

as the therapist becoming overly zealous in trying to “catch” gamblers in their lies or overly

accepting of self­reports. Either extreme can

impede the therapeutic relationship.

Strategies, Tools, and

Techniques

Engagement

In an initial contact with a pathological gambler, it is important to begin developing rapport quickly. Counselors should remember that

when a pathological gambler makes an initial

phone call to access treatment or comes in for

an initial evaluation, he or she is likely to be

feeling a great deal of shame, guilt, anxiety, or

anger. To acknowledge gambling problems is to

admit to being a “loser,” an extremely difficult

admission for most gamblers. The gambler

whose family and friends have failed to

acknowledge that he or she has a legitimate disorder also is likely to be sensitive about being

judged, criticized, and condemned.

Consequently, the clinician must demonstrate

knowledge of the signs, symptoms, and course

of pathological gambling; present a nonjudgmental attitude and empathy regarding the

emotional, financial, social, and legal consequences of gambling; and convey hope regarding the potential for recovery.

It is also important for the clinician to understand how and when to probe for greater detail

regarding the severity of the gambling disorder

and its consequences, since as with substance

abuse, the gambling client is likely to minimize

the negative impact of gambling. Clients with

COD are likely to minimize or deny the disorder for which help is not being sought.

Screening and assessment

There are several valid and reliable instruments that have been developed for the screening and assessment of pathological gambling.

Screening

The South Oaks Gambling Screen (SOGS)

(Lesieur and Blume 1987) is one of the most

widely researched instruments. This is a 20­

item questionnaire designed to screen for gambling problems and has been found to be effective in substance abuse populations. It can be

conducted as a structured interview or a selfreport questionnaire in both lifetime and past

6­month versions. The drawbacks are its length

and the fact that the items are not specifically

based on DSM­IV criteria, which precludes its

use as a diagnostic instrument. Someone who

scores above the cut­off on the SOGS would

then require a more detailed diagnostic assessment.

A brief screening tool, the Lie/Bet Questionnaire, has been found to be effective in identifying probable pathological gamblers (Johnson

et al. 1997). The questionnaire consists of two

questions:

1. Have you ever felt the need to bet more and

more money?

2. Have you ever had to lie to people who are

important to you about how much you gamble?

A “yes” response to either question suggests

potential problem gambling. Again, this instrument is likely to over­identify individuals with

gambling problems and a positive screen needs

to be followed by a more detailed clinical/diagnostic interview.

A computerized problem gambling screening

tool that may be particularly useful in criminal

justice populations is the Gambler Assessment

Specific Mental Disorders: Additional Guidance for the Counselor 429
Index (GAI), which incorporates a problem

gambling scale as one of seven scales—truthfulness, attitude, gambler, alcohol, drugs, suicide,

and stress). It takes about 20 minutes to complete and includes a descriptive computerized

printout of risk levels for all scales (Behavior

Data Systems 2000).

Assessment

A more comprehensive problem gambling

assessment needs to be part of a broader

biopsychosocial and spiritual evaluation. Only

two instruments have been studied and used to

evaluate issues of problem gambling severity.

An addendum to the ASI, the Gambling

Severity Index has been developed and validated (Lesieur and Blume 1991). Another instrument that has been found to be valid and reliable is the Gambling Treatment Outcome

Monitoring System, or GAMTOMS (Stinchfield

et al. 2001). This is a battery of four questionnaires designed to be used in assessment of

problem gambling and in treatment outcome

evaluation.

The Gambling Treatment Admission

Questionnaire (GTAQ) is particularly useful. A

162­item self­report questionnaire that incorporates the SOGS and DSM­IV criteria, the

GTAQ evaluates the range of gambling behaviors and frequency of gambling, gambling debt,

treatment history, substance use, and gambling­related financial, legal, occupational, and

psychosocial problems.

Structured interviews for the diagnosis of

pathological gambling based on DSM­IV criteria currently are being researched and developed, but are not yet publicly available

(Cunningham­Williams 2001; Potenza 2001).

Most clinicians conduct a clinical interview

based on DSM­IV criteria to establish the diagnosis of pathological gambling.

In individuals with COD, it is particularly

important to evaluate patterns of substance use

and gambling. Among those who abuse cocaine,

for example, there seem to be several common

patterns of interaction between gambling and

drug use. Cocaine use and gambling may coexist as part of a broader antisocial lifestyle.

Someone who is addicted to cocaine may see

gambling as a way of getting money to support

drug use. A pathological gambler may use

cocaine to maintain energy levels and focus

during gambling and sell drugs to obtain gambling money. Cocaine may artificially inflate a

gambler’s sense of certainty of winning and

gambling skill, contributing to taking greater

gambling risks. Cocaine may be viewed by the

gambler as a way of celebrating a win or may

be used to relieve depression following losses.

Cocaine and pathological gambling may be concurrent or sequential addictions. With cocaine

in particular, it often is difficult to have enough

money for both disorders at the same time.

There is no clear evidence that one addiction is

likely to precede another, although one recent

study reported that in a population of people

with substance use disorders who are in treatment, the onset of gambling behavior was likely

to precede the use of addictive substances (Hall

et al. 2000).

Several patterns of interaction may emerge for

individuals who are alcohol dependent and are

pathological gamblers. One of the more common clinically observed patterns is sequential

addiction; for example, someone who has had a

history of alcohol dependence—often with

many years of recovery and AA attendance—

who develops a gambling problem. Such individuals often report that they did not realize

their gambling was becoming another addiction, or that gambling could be as addictive as

alcohol and drugs. It is not uncommon for such

individuals to seek treatment only after a

relapse to alcohol (or recognizing they are close

to a relapse), secondary to the gambling­related

stresses. Other individuals have developed

alcohol problems only after their gambling has

begun to create serious adverse consequences;

they begin using drinking as a response to such

problems. Since alcohol is readily available

(and often free) in most gambling settings,

drinking and gambling may simply “go together” for some individuals.

430 Specific Mental Disorders: Additional Guidance for the Counselor
It often is helpful, if not critical, to obtain collateral information from family and significant

others. One scale that is helpful in this process,

the Victorian Problem Gambling Family Impact

Scale, is undergoing validation (Research

Evaluates Gambling’s Impact 1998).

Obtaining collateral information often can be

challenging, as the gambler may want to control

both what the clinician knows and what the

family knows. The gambler may not want the

clinician to know how angry and devastated the

family is feeling, or the gambler may not want

the family to know the extent of his or her gambling and gambling debt. Also, the gambler may

give specific instructions to family members

about what to tell or not to tell the clinician.

This may be related to gambling or finances,

but it also may relate to substance use.

Therefore, while it is advisable to involve family

members as early as possible in the assessment

and treatment process, it may take time to

develop a trusting clinical relationship with the

gambler before he or she gives consent to family

involvement. The clinician needs to consider

carefully the best way to involve family members or significant others in the assessment and

treatment process. Initial sessions with both the

gambler and family present may help to alleviate the gambler’s anxiety. Such sessions can be

followed up with meetings without the gambler

present. It is essential that the therapist not be

viewed as taking sides in this process.

Crisis stabilization

Pathological gamblers frequently come into

treatment in a state of panic and crisis. The

attempted suicide rate among gamblers in

treatment is high (20 percent) (NRC 1999),

which makes a careful evaluation of suicide

potential essential. A common suicide plan for

PG clients is to have an automobile accident so

that family can collect life insurance to pay off

gambling debts. Concurrent substance use adds

to the risk potential for self­harm, so it is

important that the gambler who is at risk for

suicide contracts not to use any mind­altering

substances in addition to not endangering

Case Study: Pathological Gambling Assessment 

A 36­year­old, married male, Andy J. entered treatment for pathological gambling. An initial assessment

involving questionnaires and structured diagnostic interviews found indications of excessive alcohol use and

use of cocaine. On a family assessment interview, Andy J.’s wife denied knowledge of any excessive alcohol

use or any cocaine use on her husband’s part.

As treatment proceeded, it became apparent that Andy J.’s substance use was more extensive and problematic than first presented. Staff members were particularly concerned about his apparent hiding of his substance use from his spouse. Andy J. became angry and agitated, threatening to discontinue treatment when

staff indicated that the issue of his substance abuse needed to be addressed at the next family session. Andy

J. was given the choice of communicating the extent of his substance use to his wife prior to the session or

waiting until the session.

Andy J. initially withdrew consent to communicate with his wife. However, after intensive group and individual work focusing on relapse potential, dishonesty as a relapse risk factor, and assessment of further negative consequences, he decided to tell his wife. In the next joint session, his wife expressed relief and reported that she had been aware of and concerned about his substance use. She had lied at the initial assessment

at her husband’s request, as he had convinced her that it would be best for his treatment not to get the therapist distracted by his substance use so that he could fully focus on his gambling problem. Andy J., once the

initial anger and anxiety had subsided, acknowledged that he was holding onto his substance use for fear of

living life without an addiction to fall back on. He realized that continued substance dependence would continue to maintain all the problems he was attributing only to his gambling.

Specific Mental Disorders: Additional Guidance for the Counselor 431
him/herself or others. (However, as noted in

the discussion of suicide, counselors should not

rely solely on such contracts.) Placement in a

structured environment, inpatient, or residential setting may be necessary in some cases.

Addressing financial and legal

issues

Financial crises may involve eviction and

homelessness; inability to pay for food or utilities; or families discovering that savings

accounts, college funds, and so on are totally

depleted. It is important in handling financial

crises to make sure the basics of food and shelter are met for the gambler and his family. This

may mean referring the family to homeless

shelters or finding temporary living quarters

with extended family. Resolving the entire

extent of financial problems takes more time;

however, in the crisis situation it is essential to

convey to the gambler and family that coping

with financial stress is a part of treatment, and

to outline the process for addressing the problems. It is important to help the gambler and

family prioritize immediate needs (i.e., food,

shelter) separately from those that can be managed later to relieve the feelings of being overwhelmed. The counselor can help the client

make specific lists of what can be done now and

what can wait until later. For example, if the

family is being evicted, the clinician could provide a list of shelters to call or have the client

call shelters from the clinician’s office.

Legal issues can create an additional crisis for

the pathological gambler and the family.

Embezzling from an employer or writing bad

checks are two common illegal practices of

pathological gamblers. When facing potential

legal charges for such activities, the gambler

often is in a state of panic, looking for money to

borrow from family or friends to pay off the

checks or pay the employer back to avoid legal

consequences. It often is difficult for the family

or friends of the gambler to refuse such

requests when they fear the result will be sending the gambler to jail. In such cases, the clinician needs to direct the gambler to obtain legal

counsel prior to making impulsive decisions.

The clinician needs to work with both the gambler and potential “bail out” sources to explore

other options.

Financial and legal issues also can trigger

domestic violence. The pathological gambler

may face physical violence from a spouse or

significant other when he or she confesses to

the extent of gambling debt. Alternatively, a

spouse or significant other may face violence if

he or she attempts to withhold money from the

pathological gambler. The clinician needs to

assess the history of domestic violence or potential for violence very carefully before suggesting

any plan for dealing with money management

or financial disclosure.

Self­banning

To assist a client with a PG problem to abstain

from gambling, some gambling venues (mainly

casinos and some race tracks) offer “self­banning.” This is a process of completing a written

document indicating a desire to be prohibited

from entering a casino or race track. Some

States have made this a legal process with criminal consequences if a gambler who has selfbanned is found gambling at the banned location. Information on this process can be

obtained from the gambling venue’s responsible

gaming office, from State Councils on Problem

Gambling, or from State­funded problem gambling treatment programs.

Short­term care and 

treatment

This section will first discuss specific treatments

that have been used in the treatment of pathological gambling, then explore how this knowledge can be applied to the pathological gambler

with a substance use disorder. Although a broad

range of treatment modalities have been applied

to the treatment of pathological gamblers, to

date there has been little research to support

one type of treatment over another.

Psychodynamic therapies

Some of the earliest clinical writing on the successful treatment of pathological gambling was

based on psychodynamic approaches. Such

432 Specific Mental Disorders: Additional Guidance for the Counselor
Case Example: Counseling a Pathological Gambler 

Michael B. was a gambler who relished the competitiveness of card playing and had developed a reputation

as a tough player and as a winner early in his gambling career. His gambling gradually became out of control

and it was clear that he was unable to stop gambling until he had lost all his money. However, when he

attempted to abstain from gambling he would feel depressed. In treatment he confessed to feeling increasing

anxiety when he was winning, and to feel relief only when he had lost everything.

Michael B.’s father had been a successful business executive who had been very demanding and critical of

Michael B. throughout his life. Michael B. had been determined to “beat his father at his own game” and

become even more successful. While Michael B. had developed many businesses, they always seemed to collapse after an initial success, a pattern that mimicked his gambling. In therapy, it became clear that Michael

B. felt guilty at thoughts of “beating” his father, which contributed to the destructive pattern of his gambling

and of his unsuccessful businesses.

Treatment helped Michael B. let go of his guilt­producing fantasy of spectacular success and focus on how he

could enjoy his life without feeling a need to compete with his father. He was able to set more realistic goals

to achieve a sense of accomplishment and was able to abstain from gambling without feeling depressed and

inadequate.

approaches emphasize identifying the underlying conflicts and psychological defenses that

contribute to addictive gambling. Therapy

involves helping the gambler gain insight into

the psychological meaning of his or her gambling (Rosenthal and Rugle 1994), decreasing

defenses that support denial and irrational

thinking, and developing more adaptive coping

skills to resolve internal conflicts. Such dynamic therapies generally are incorporated into a

comprehensive treatment approach with the

therapist taking a more active and directive

role than in traditional dynamic approaches.

Cognitive–behavioral treatment

While early reports of behavioral treatment of

pathological gambling focused exclusively on

gambling behaviors using aversive conditioning

and systematic desensitization, more recent

approaches involve a range of cognitive as well

as behavioral interventions. Similar to

approaches to substance use disorders, these

include relapse prevention strategies, social

skills training, problem solving, and cognitive

restructuring (Sharpe 1998).

A component that is specific to pathological

gambling in this strategy involves modifying

irrational beliefs about gambling and the odds

of winning. Research repeatedly has shown

that gamblers hold beliefs in “the illusion of

control,” biased evaluation, and the gambler’s

fallacy (Ladouceur and Walker 1998).

• The illusion of control is the belief that one

can control or influence random or unpredictable events, such as picking winning lottery numbers or controlling the fall of the

dice by how they are thrown.

• Biased evaluation involves attributing wins to

one’s special skill or luck, while losses are

blamed on external circumstances.

• The gambler’s fallacy is the misunderstanding of independent probabilities. For example, if a coin is tossed 10 times resulting in 10

heads, one would think it more likely to get a

tail on the next toss, rather than realizing the

odds of a head or tail is the same for any one

toss.

Cognitive–behavioral interventions are targeted

at identifying and correcting such irrational

thinking and erroneous beliefs.

As with substance abuse, relapse prevention

includes identifying gambling­related internal

and external triggers. Money is a common trigger and interventions generally involve removSpecific Mental Disorders: Additional Guidance for the Counselor 433
ing money from the gambler’s control. This can

include removing the gambler’s name from

joint checking and savings accounts, limiting

the amount of cash the gambler carries, discontinuing credit cards, and choosing a trusted

family member or friend to become the gambler’s money manager. As might be anticipated,

this can be a difficult and conflictual process;

successful use requires creativity and sensitivity to issues of power and control. The goal is

not only to remove the trigger of money from

the gambler, but also to protect the gambler’s

and the family’s finances. It can be helpful if

this is explained as a process of assisting the

gambler in regaining financial control of his or

her life. Negotiating a workable and tolerable

system of financial accountability and safety is

a key therapeutic task in the treatment of

pathological gamblers, regardless of therapeutic approach.

With clients with co­occurring PG and substance use disorders, it often is essential to

identify specific triggers for each disorder. It

also is helpful to identify ways in which use of

addictive substances or addictive activities such

as gambling act as mutual triggers.

Increasing evidence supports the effectiveness

of treatment approaches with the goal of

reduced or limited gambling, particularly for

problem gamblers who do not meet all criteria

for a diagnosis of pathological gambling or

who are low­severity pathological gamblers.

This approach generally involves money management along with cognitive–behavioral interventions to set and achieve goals for controlled or limited gambling. Manuals are available to guide this type of treatment, and a

self­help manual also has been published

(Blaszczynski 1998).

Psychopharmacological treatment

Two main types of medication have been

reported to reduce gambling cravings and gambling behavior: SSRIs, such as fluvoxamine

(Luvox), and opiate antagonists, such as naltrexone, which has also been found to be effective in treating people with substance use disorders (Hollander et al. 2000; Kim et al. 2001).

As people with co­occurring substance use and

PG disorders may be more likely to experience a broad range of additional mental disorders, psychiatric medication to address affective disorders, anxiety disorders, and attention deficit hyperactivity disorder may sometimes be needed.

Integrated multimodal treatment

Treatments combining 12­Step, psychoeducation, group therapy, and cognitive–behavioral

approaches have been found to be effective in

the treatment of pathological gamblers with cooccurring substance use and mental disorders

(Lesieur and Blume 1991; Taber et al. 1987).

Gamblers Anonymous

It is advisable for persons with substance use

and PG disorders to attend separate support

groups for gambling and for alcohol and/or

drug dependence. While the groups can supplement each other, they cannot substitute for

each other.

It may be difficult for some individuals to

adjust to both types of groups, as Gamblers

Anonymous (GA) meetings can be different

from AA. It is not uncommon for people with

substance use disorders who have had extensive experience with AA, Narcotics

Anonymous, or Cocaine Anonymous to find

fault with GA groups. While GA often places

less emphasis on step work, sponsorship, and

structure than other 12­Step programs, it still

provides a unique fellowship to address gambling issues. GA also can be useful in helping

gamblers and their families cope with money

management, debt, and restitution issues

through a process called “Pressure Relief.”

Clinicians new to the treatment of pathological

gambling are advised to attend open GA and

Gam­anon meetings in their area to gain a better understanding of this support system.

The experience of some clinicians is that initially, limited gambling may be an approach for

those with substance use disorders and gambling problems who are willing to work on

abstinence goals for their substance use, but

who are less motivated to abstain from gam434 Specific Mental Disorders: Additional Guidance for the Counselor
bling. Rather than distracting from the substance abuse treatment, the clinician can suggest either a limited gambling approach or a

time­limited period of abstinence from gambling. These may be presented as experiments.

Cravings for both gambling and substances can

be monitored in either approach to help clients

understand the potential interactions of both

disorders and to make better informed decisions about whether they can gamble at all.

The same can be done with the client who is

motivated to abstain from gambling but more

ambivalent about the need to reduce his or her

substance use or abuse. This approach may

help minimize a client’s defensiveness toward

treatment in general and reduce the risk of

dropping out of treatment or denying a problem altogether.

Longer term treatment

PG, like substance use disorders, may be conceptualized as a chronic, recurring disorder.

Potential for lapses and relapses must be recognized for both disorders—and perhaps particularly for people with both disorders. It is

important to educate clients about this possibility, if not likelihood, and to develop a plan for

re­engaging in treatment if a lapse or a relapse

occurs. Professionally facilitated continuingcare groups that focus on recovery maintenance skills can be effective, particularly in

combination with mutual self­help groups.

Continuing­care groups often can be facilitated

by peer counselors or treatment program alumni with several years of abstinence. Such continuing­care groups particularly may be useful for

clients with COD to maintain contact with therapy resources, to help “catch” a relapse in the

making, and to supplement limited availability

of GA in many communities. Development of a

treatment alumni network also can be a useful

strategy to maintain contact with clients over

longer periods of time and to increase the likelihood of using supportive resources in times of

stress, vulnerability, or crisis.

Case Study: Counseling the Client With Pathological

Gambling and Substance Use Disorders

Jan T. is a 32­year­old divorced, single parent with a history of cocaine and marijuana dependence, alcohol

abuse, and two prior treatments for her substance use disorders. She entered treatment following a bout of

heavy drinking resulting in a citation for Driving Under the Influence (DUI). During assessment, she

screened positive on the SOGS for probable pathological gambling. She had been going to casinos several

evenings per week, losing on average $200 to $500 per week playing video poker. Her rent and utilities were

past due, and she feared losing her job due to tardiness and inefficiency because often she would go to work

after staying up all night gambling. She had begun drinking while gambling after a 2­year abstinence from

substances, and her drinking had increased as her gambling problems progressed.

Jan T.’s DUI occurred while driving home from an all­night gambling episode. Her gambling had begun to

increase following her first substance abuse treatment and she acknowledged that her alcohol relapse after

her first treatment was related to her gambling, as was her current relapse. She reported having increased

her gambling due to feelings of stress and loneliness. As her gambling increased, she discontinued going to

continuing care and AA and Cocaine Anonymous meetings. However, in her second substance abuse treatment, no one had asked her about her gambling and she did not recognize it as a problem at the time.

Current treatment emphasized her gambling problems as well as substance abuse. She attended gambling­specific education and therapy groups as well as AA, Cocaine Anonymous, and GA meetings. Due to serious, continuing financial problems and debt, Jan T. moved in with an older sister who had a 12­year history of abstinence from alcohol and attended AA meetings regularly. This sister also agreed to be her money manager.

Specific Mental Disorders: Additional Guidance for the Counselor 435
Since Gam­anon groups are even less prevalent

than GA groups, continuing­care groups for

family members or for family members and PG

clients jointly particularly can be useful to provide support for coping with financial issues

that may persist for many years despite gambling abstinence.

Resolving financial problems and accomplishing debt repayment also can be a relapse trigger for pathological gamblers, so often it is

important to schedule a “check up” visit

around the anticipated time when gambling

debts may be paid off. In general, it may be

advisable to attempt to maintain therapeutic

contact beyond the gambler’s 1­year anniversary of abstinence, since often this seems to be

a time of vulnerability, overconfidence, and

complacency regarding recovery.

436 Specific Mental Disorders: Additional Guidance for the Counselor
Appendix E:

Emerging Models

Part I of this appendix provides information on where to seek further

information for models referenced in the main body of the TIP. Part II

describes models of care for people with COD that were evaluated or are

currently being evaluated with funding by the Substance Abuse and

Mental Health Services Administration (SAMHSA) or other Federal

agencies. Because these models are undergoing evaluation, they are not

endorsed by the consensus panel as consensus­based practices. Rather,

the models are intended to augment those described in the main body of

the TIP and to represent some initiatives. It is hoped that these models

will suggest ways in which readers working with a variety of client populations, disorders, or severities in different settings can improve their

capacities to assess and treat clients with COD.

Material for this chapter was derived from responses to a request for

information sent to programs listed in SAMHSA initiatives in 2002. The

programs were invited to describe essential aspects of their programs

and empirical information on outcome data. All initiatives canvassed are

listed at the end of this appendix. The models included in this appendix

are from programs that responded to the request.

Part I: Addresses for Models

Referenced in the Text

Arapahoe House

Michael W. Kirby, Jr., Ph.D.

CEO

Arapahoe House, Inc.

8801 Lipan Street

Thornton, CO 80260

Phone: (303) 657­3700

E­mail: mick@ahinc.org

437
Ellen Brown, Ph.D.

Same address and telephone number

E­mail: ellen@ahinc.org

Clackamas County Mental

Health Center

Clackamas County Mental Health Center

Alcohol and Drug Program Manager

524 Main Street

Oregon City, OR 97045

CMHS/CSAT Collaborative

Program to Prevent

Homelessness

Colleen Clark, Ph.D.

Principal Investigator

Boley Centers for Behavioral Health Care, Inc.

St. Petersburg, FL 33713

Phone: (727) 821­4819

Fax: (727) 822­6240

Web site: http://www.boleycenters.org

Community Connections

Rebecca Wolfson Berley, M.S.W.

Director of Trauma Education

Community Connections

801 Pennsylvania Avenue, SE

Suite 201

Washington, DC 20003

Phone: (202) 608­4735

Fax: (202) 608­4286

E­mail: rwolfson@communityconnectionsdc.org

Web site: http://www.communityconnectionsdc.org

(For more description see Part II of this

appendix.)

The Dual Assessment and

Recovery Track (DART)

Stanley Sacks, Ph.D., Principal Investigator

Center for the Integration of Research and

Practice

National Development and Research Institutes,

Inc.

71 West 23 Street, 8th Floor

New York, NY 10010

Phone: (212) 845­4648

Fax: (917) 438­0894

Evaluation of a Treatment

Model for Co-Occurring and

Traumatic Stress Disorder

Linda K. Frisman, Ph.D.

Principal Investigator

Connecticut Department of Mental Health and

Addiction Services

Hartford, CT 06134

Phone: (860) 418­6788

Fax: (860) 418­6692

E­mail: Frisman@uconnvm.uconn.edu

Foundations Associates

Contact information, detailed program materials, and research findings may be obtained via

Foundations’ Web site at http://www.dualdiagnosis.org.

Gaudenzia, Inc.

Karen Griffin, Director of Administration

Gaudenzia Corporate Offices

106 W. Main Street

Norristown, PA 19401

Phone: (610) 239­9600 x 231

E­mail: kgriffin@Gaudenzia.org

438 Emerging Models
Harborview Medical Center’s

Crisis Triage Unit (CTU)

Rick Ries, Director of Outpatient Psychiatry,

Addictions, and Dual Disorders Services

Harborview Medical Center

Box 359911

325 Ninth Avenue

Seattle, WA 98104

Phone: (206) 341­4216

Fax: (206) 731­3236

E­mail: rries@u.washington.edu

HIV Integration Project of the

CORE Center

Director, Behavioral Sciences

The CORE Center

2020 W. Harrison Street

Chicago, IL 60612

Phone: (312) 633­4915

Homelessness Prevention TC

for Addicted Mothers

Jo Ann Sacks, Ph.D., Principal Investigator

Center for the Integration of Research &

Practice

National Development & Research Institutes,

Inc.

71 W 23rd St., 8th Floor

New York, NY 10010

Phone: (212) 845­4648

Fax: (917) 438­0894

Na’nizhoozi Center, Inc.

Raymond Daw, M.A., Executive Director

Na’nizhoozi Center, Inc.

2205 East Boyd Drive

Gallup, NM 87301

Phone: (505) 722­2177

Fax: (505) 722­5961

E­mail: raydaw@aol.com

Project SPIRIT: Seeking

Pathways Into Receiving

Integrated Treatment

Roy M. Gabriel, Ph.D., Principal Investigator

RMC Research Corporation

522 SW Fifth Avenue, Suite 1407

Portland, OR 97204

Phone: (800) 788­1887 or (503) 223­8248

Fax: (503) 223­8399

E­mail: roy_gabriel@rmccorp.com

Triad Women’s Project

For more information on the Triad Women’s

Project, consult the following Web site:

http://mhlp.fmhi.usf.edu/research/rdetail.cfm?prid=109

Part II: Other Emerging

Models

Case Management for Rural

Substance Abuse

This project evaluates the effectiveness of case

management with adult clients in residential

treatment for drug abuse. The results of this

study will be helpful to service providers and

policy developers as they plan drug treatment

interventions, especially in rural areas.

Contact information

James Hall, Ph.D., LISW

Principal Investigator

University of Iowa

Iowa City, IA 52242

Description of intervention

The overall goal of this study is to provide

insight into the development of case management models for substance abuse treatment

and to improve quality of life for rural substance abuse clients. The purpose of this project is to conduct a full study of case management treatment services and to evaluate the

Emerging Models 439
effectiveness of three case management models:

brokerage (IBCM), comprehensive (ICCM),

and standard treatment (SCM). The conceptual

model used is the health services framework of

Aday et al. (1993). In this framework, the population at risk is evaluated for predisposing,

enabling, and need variables.

Setting

Clients were recruited for the study from the

residential program at the Mid­Eastern Council

on Chemical Abuse (MECCA), which was also

the site for our earlier study on case management. As a facility receiving State funds,

MECCA participates in the State­funded managed care program. MECCA has a catchment

area comprising four counties and is governed

by community representatives from the fourcounty area. MECCA’s main office is in Iowa

City, IA, with satellite offices in Coralville,

Marengo, and Washington, IA. Total population for MECCA’s catchment area is 148,000

(1990 census), comprising 90 percent white, 2

percent African American, and 3 percent other

races. Roughly 75 percent of MECCA’s clients

are insured by a source that falls under the

IDPH managed care plan.

MECCA has a 20­bed residential unit with

additional beds in a halfway house, a detoxification unit, and outpatient and educational

programs for adults and adolescents. Adult

clients are referred to MECCA from a variety

of sources, including hospitals (7 percent),

other health and social service agencies (7 percent), the legal system (30 percent), family and

friends (6 percent), committals (10 percent),

and self­referrals (40 percent). Approximately

2,400 people are evaluated in person by

MECCA intake counselors annually to determine a treatment recommendation. The intake

screening uses Iowa’s Level of Care (LOC

Determination Form), which determines treatment placement according to American Society

of Addiction Medicine (ASAM) Criteria.

Client characteristics

The target population for this study of rural

clients in substance abuse treatment is residential clients of one Midwestern not­for­profit

substance abuse treatment center, MECCA.

Approximately 380 clients per year meet criteria required for an admission to MECCA’s

adult residential program. Clients in the residential program may receive up to 50 hours of

treatment services weekly, including group and

individual therapy, life skills training, and

other education classes. The average age of

MECCA residential clients is 33.9. Forty­two

percent are female, 84 percent are white, 12

percent are African American, 4 percent are

other races. Fifty­eight percent are unemployed. Sixty­one percent have no health insurance, 19 percent have Medicaid, Medicare, or

other public coverage. Eight percent are homeless. Forty­nine percent of residential clients

have been diagnosed with a psychiatric condition prior to the admission. Ninety percent

have used alcohol steadily for at least 1 year in

their lifetime, 70 percent have used marijuana,

47 percent have used cocaine, and 48 percent

have used amphetamines. Residential clients

have been arrested an average 7.8 times in

their lifetime. Data collected at MECCA during

our previous study indicates that 49 percent of

female and 13 percent of male residential

clients have been sexually abused in their lifetime; 72 percent of female and 42 percent of

male residential clients reported being physically abused in their lifetime. Regarding HIV­associated behaviors, 29 percent of MECCA clients

have used substances intravenously and 29 percent have had sex with someone they knew was

using substances intravenously.

Resources needed for 

implementation

In this study, we are evaluating two models of

case management, comprehensive and brokerage, compared with standard treatment. Case

managers who use the comprehensive model

provide mental health counseling as part of

that service. For those clients receiving services

440 Emerging Models
with the brokerage case manager, they are

referred for mental health services (if needed)

based on their ability to pay; those with insurance have more options in our area than those

on public funding.

We have a manual for both models, but training would be needed to carry out either model

with competency. In our area, cultural competency also includes working with those from

rural areas as well as smaller towns. We have

found that our case managers can help clients

overcome barriers to services through education, direct referral, and transportation.

Empirical data

The primary analysis of outcome data focuses

on drug use by condition. Preliminary analysis

shows overall drug use decreased from intake

through both follow­up evaluation points for

each drug class. The main drugs of use were

alcohol, cocaine, marijuana, and methamphetamine. For these four drug classes, clients

receiving comprehensive case management

reported a significant decrease from intake to

the 3­month followup and then reported a

smaller decrease by the 6­month session.

Clients in the standard treatment condition

also reported a significant decrease in use of

these four drugs from intake to the 3­month

session, although no decreases were noted by

the 6­month session. Clients receiving brokerage case management reported a significant

decrease in use from intake to the 3­month session, but at the 6­month point, they reported

moderate increases.

Publications 

Hall, J.A., Carswell, C., Walsh, E., Huber,

D.L., and Jampoler, J. Iowa case management: Innovative social casework. Social

Work, in press.

Hall, J.A., Vaughan, M., and Rick, G. Iowa

case management for rural substance abuse:

Preliminary results. Journal of Case

Management. Under review.

Hall, J.A., Vaughan, M.S., Vaughn, T., Block,

R.I., and Schut, A. Iowa case management

for rural drug abuse: Preliminary results.

Care Management Journals 1(4):232–243,

1999.

Huber, D.L., Hall, J.A., and Vaughn, T. The

dose of case management interventions.

Lippincott’s Case Management 6(3):119–126,

2001.

Ingram, J., Vaughan, M.S., and Hall, J. The

effectiveness of case management for substance abuse clients with mood or anxiety disorders. To be submitted to Psychiatric

Services.

Kehrli, A.J. Access and utilization of case management services with substance abusing

clients. In development.

Vaughan, M.S., Hall, J.A., Richards, B., and

Carswell, C. A comparison of computerbased versus pencil and paper assessment of

drug use. Research on Social Work Practice,

in press.

Vaughan, M.S., Hall, J.A., and Rick, G.

Impact of case management on use of health

services by rural clients in substance abuse

treatment. Journal of Drug Issues

30(2):435–464, 2000.

Vaughan, M.S., Huber, D., and Hall, J.A.

Impact of Iowa case management on family

functioning for substance abuse treatment

clients. Adolescent and Family Health, in

press.

Vaughn, T., Vaughan, M.S., Saleh, S., and

Hall, J.A. Participation and retention in

drug abuse treatment services research.

Submitted to Journal of Substance Abuse

Treatment.

Emerging Models 441
CMHS/CSAT Collaborative

Effort to Prevent

Homelessness

Contact information

Colleen Clark, Ph.D.

Principal Investigator

Department of Mental Health Law and Policy

MHC 2732

Florida Mental Health Institute

University of South Florida

Tampa, FL 33612

Phone: (813) 974­9022

Fax: (813) 974­9327

E­mail: cclark@fmhi.usf.edu

Description of intervention

The Boley Homelessness Prevention Project

provides quality housing, housing­related support services, and linkages to a wide array of

psychosocial, clinical, and medical services.

Services range from immediate needs (food,

shelter, clothing) to permanent housing and

vocational training for individuals who are

homeless and have mental illnesses or co­occurring substance use disorders. The program

provides housing or assists clients in finding

housing of their choice, and then provides

housing­related support services. The Boley

Centers employ a psychiatric rehabilitation

approach that incorporates the Fellowship

House and Fountain House models and the

case manager specialist model.

Setting

Located in West Central Florida, Boley Centers

for Behavioral Healthcare, Inc., is a private

nonprofit agency providing psychosocial rehabilitation services since 1970 for people with

severe mental illnesses who may also have substance use disorders. Boley provides an array

of residential and supportive services to over

600 persons at any given time and about 1,000

people in any given year.

Patient characteristics

The Boley Homelessness Prevention Project is

an important program of Boley Centers. Of the

92 individuals served in 1996, all individuals

had been homeless or at risk of homelessness

when they entered the program. The “model”

person served would be male, white, never

married, in his forties, with a primary diagnosis of a psychotic disorder and a secondary

diagnosis of a substance use disorder.

Resources needed for 

implementation

The most important aspect of staff training is

training in a psychosocial rehabilitation model.

This may come either from formal training outside the agency or through mentoring within

the agency. Staff­resident interactions are considered vital to the effectiveness of the intervention and are based on mutual respect. The

model emphasizes providing services as needed

and or/requested rather than mandatory or

prescribed services.

Funding for services in the project follows a

fairly typical pattern of community mental

health agencies, i.e., a combination of State

ADM (alcohol, drugs, or mental disorders) and

Medicaid funding with some county and other

patient fees. Boley Centers is a model of innovation for funding the acquisition and rehabilitation of housing. Each housing site may have a

different combination of HUD, City Revitalization, County, private gifts, and client fees.

Although initially met with a “NIMBY” attitude, they have developed a reputation for

revitalizing urban neighborhoods and are now

sought­after partners in housing and planning.

Empirical data

The results of the meta­analysis of eight sites

studied in the CMHS/CSAT Collaborative

Program to Prevent Homelessness strongly

supported programs, including Boley, that

guarantee housing and provide housing support services. These significant effects are being

written up have not been published to date.

442 Emerging Models
In addition, our local analysis demonstrated

that, for people with relatively high levels of

psychiatric symptoms and substance use, the

Boley intervention was more effective than specialized case management in helping to maintain stable housing. For people with relatively

low or moderate levels of symptoms and substance use, specialized case management was

equally effective. These findings are summarized in publications below.

Publications

Descriptive publications

Boley Centers for Behavioral Health Care,

Inc.: The Homelessness Prevention Project—

1996­1997: A Descriptive Manual.

This is a comprehensive description of the conceptual framework, environmental context,

development of the intervention, client population, structure, and process of the intervention,

the agency/community network, evaluation

activities, residents’ stories, and lessons

learned and recommendations. It is available

from Colleen Clark (see above for contact

information).

Clark, C., and Rich, A. “Boley Centers for

Behavioral Health Care, Inc.: Housing

Related Support Services.” Reinforcing

Upstream: Interim Status Report of the

Center for Mental Health Services and

Center for Substance Abuse Treatment

Collaborative Effort to Prevent

Homelessness, 1999.

Clark, C., and Rich, A. “Boley Homelessness

Prevention Project: Final Report.” Final

project deliverable to the CMHS/CSAT

Collaborative Program to Prevent

Homelessness, 2000.

Clark, C., Teague, G., and Henry, R.

Prevention of Homelessness in Florida. Copublished simultaneously in Alcoholism

Treatment Quarterly 17(1/2): 73–91; and in

Conrad, K. et al., eds. Homelessness

Prevention in Treatment of Substance Abuse

and Mental Illness; Logic, Models, and

Implementation of Eight American Projects.

The Haworth Press, Inc., 1999. pp. 73–91.

Publications of the outcomes

Clark, C. Policy Brief 14: Ending

Homelessness Among Person with Serious

Mental Illness: What Works Best for Whom?

Louis de la Parte Florida Mental Health

Institute Series. November, 2001.

Clark, C., and Rich, A. Ameliorating homelessness for adults with mental illness: What

works for whom? Psychiatric Services, in

press.

CODAC Behavioral Health:

Managing Co-Occurring

Disorders in an Opioid

Agonist Setting

Contact information

James C. Carleton, M.S.

Director of Opioid Treatment Services

CODAC Behavioral Health

1052 Park Ave.

Cranston, RI 02910

Phone: (401) 275­5039

Fax: (401) 942­3590

E­mail: jcarleton@codacinc.org

Description of intervention

This program provides uninsured methadone

clients with psychiatric evaluation, care, medication, and casework, all at no cost. It was

developed on the premise that a client seeking

treatment should find “no wrong door” that

might impede progress in finding help of this

nature. Given this, a client seeking help for

emotional problems, lacking the means to

access these services, is referred, evaluated,

and treated onsite in the Co­Occurring

Disorders Program. The program is a collaborative effort of CODAC Behavioral Health, a

substance abuse and behavioral disorders

treatment facility, and Gateway Healthcare, a

large, multi­site, mental health center. It is

Emerging Models 443
staffed by a Psychiatrist (Gateway), Licensed

Mental Health Professional (CODAC), and

Caseworker (Gateway). Twice per week, onsite

at the CODAC Providence methadone clinic,

clients are seen and treated on referral from

the methadone treatment staff. As a result,

CODAC clients receive “methadone friendly”

psychiatric care, in a timely fashion, onsite at

their primary clinic. They are followed afterhours as if they were ordinary clients of the

prescribing psychiatrist at Gateway

Healthcare.

Setting

The Co­Occurring Disorders Program is located at CODAC Behavioral Health’s Providence,

RI, location. Gateway Healthcare, the collaborative psychiatric treatment component, is

located in nearby Pawtucket, RI. CODAC

Behavioral Health, historically a substance

abuse treatment facility, is in its 30th year.

CODAC serves approximately 2,200 clients,

out of which 1,050 are agonist clients, utilizing

both methadone and LAAM.

Client characteristics

All of the clients who participate in the CoOccurring Disorders Program are opioid agonist clients of CODAC Behavioral Health. They

are referred on a voluntary basis. None have

health insurance or related benefits.

The gender breakdown is 60 percent female, 40

percent male. The average client age range is

late thirties to early forties. The racial breakdown, from most to least, is Caucasian,

Hispanic, and African American.

The most common diagnosis treated is that of

Mood Disorder. This would include depressive

disorders, dysthymic disorders, bipolar I and

II, and cyclothymic disorders. Also common

are Anxiety Disorders, to include panic, agoraphobia, obsessive­compulsive disorder, and

posttraumatic stress disorder. Many clients also

carry the diagnosis of Personality Disorder,

coded on Axis II.

In terms of severity, all clients are outpatient

and are required to make multiple trips to the

clinic each week. Several clients have been hospitalized while under our care, and aggressive

casework managed to provide continuity of

treatment.

Resources needed for 

implementation

This project is entirely funded by a grant from

the Department of Mental Health, Retardation,

and Hospitals, Division of Substance Abuse,

State of Rhode Island. We are in the first year

of a 3­year project.

Medication is provided free of charge, through

a State­administered program, the Community

Mental Health Medication Assistance Program

(CMAP).

Successful implementation required cooperation on a number of levels. CODAC and

Gateway needed to effectively collaborate to

design the program and win a competitive bid

process. That accomplished, we desired regulatory cooperation to site the program at an

existing methadone treatment facility, and

practice psychiatric medicine. Further, we

required regulatory approval to qualify our

clients for CMAP, and free medication, if within a restricted formulary. Finally, the program

was designed to be attractive to clients, and

existing methadone staff. It needed to fit well

with the present services and be accessible to

referring staff and clients. Built into the program was a series of inservice trainings

designed to educate the staff regarding the service, and its obvious benefits.

In summary, establishing a program of this

nature requires collaboration between multiple

systems. One must have the expertise to design

and fund a project. Cooperation between three

or more regulatory bodies is involved as you

site a non­traditional service in an established,

substance abuse treatment facility. Finally, the

value of the service must be stressed to the ultimate consumers, and the intrasystem referral

sources. Dependent on the demographics of

444 Emerging Models
your locale, it may be essential to have bilingual, culturally competent staff. The program’s

credibility will depend on it.

Empirical data

Program evaluation provides for a number of

measures to assess the level of success. As these

are clients on a methadone treatment program,

some well­defined indicators emerge. First, toxicology screening tells us whether the client is

drug­free. It is hoped an effective mental health

intervention will reduce illicit drug use.

Second, an empirical, 32­item scale, the

BASIS­32, is administered at 3­ and 6­month

intervals. This scale rates a client’s progress

along five areas of difficulty: relation to

self/others, depression/anxiety, living skills,

impulsive/addictive, and psychosis. Third, the

overall behavior and demeanor of the client is

evaluated by the behavioral health specialist.

We are still early on in the data collection process; however, the first set of results appears to

be trending positive.

The data are unpublished at this point. Our

plan is to collect 12 months’ worth of evaluation data prior to publication.

Publications

There are no publications associated with this

program.

Community Connections

Contact information

Rebecca Wolfson Berley, M.S.W.

Director of Trauma Education

Community Connections

801 Pennsylvania Avenue, SE

Suite 201

Washington, DC 20003

Phone: (202) 608­4735

Fax: (202) 608­4286

E­mail: rwolfson@communityconnectionsdc.org

Web site: http://www.communityconnectionsdc.org

Description of Intervention

Community Connections, a provider of comprehensive human services in Washington, DC,

is the lead agency for the DC Trauma

Collaboration Study (DCTCS). This project

was funded by SAMHSA to develop and evaluate the effectiveness of services for women trauma survivors with co­occurring substance use

and mental disorders. Agency staff developed a

comprehensive, integrated, trauma­focused

network of services with four key intervention

components: Trauma Recovery and

Empowerment Model (TREM) groups,

Integrated Trauma Services Teams (ITSTs),

Collateral Groups (on issues such as substance

abuse, parenting, domestic violence, and spirituality), and a peer support program.

Setting

The experimental sites are two community

mental health and substance abuse treatment

programs in Washington, DC: Community

Connections and Lutheran Social Services. The

control sites are two similar programs in

Baltimore, MD: North Baltimore Center and

People Encouraging People.

Client characteristics

Women enrolled in the study had histories of

trauma (physical and/or sexual abuse) as well

as a substance abuse diagnosis and a mental illness diagnosis (at least one current and one

within the past 5 years).

Resources needed for 

implementation

Primary clinicians received cross­training in

trauma, mental health, and substance abuse

problems and related interventions. Consumersurvivors were involved in planning, implementing, and evaluating the project; they also

developed a Women’s Support and

Empowerment Center to provide peer support

services.

Emerging Models 445
Empirical data

Preliminary findings from the DCTCS indicate

that the TREM intervention is feasible (that

clinicians can learn to implement it in a consistent way with fidelity to the treatment manual);

that consumers complete it at high rates (over

75 percent of the women involved in the first

eight groups completed more than 75 percent of

the sessions); and that consumer satisfaction is

very high. Other early outcome data suggest

that this integrated package of services built

around the central TREM group intervention is

helpful to participants in both substance abuse

and mental health domains. Pilot data collected

in other program evaluation projects suggest

potential benefits for TREM participants in a

number of outcome domains: decreased mental

health symptoms, increased recovery skills,

and enhanced overall functioning; reduced utilization of inpatient hospitalization and emergency rooms; and decreased high­risk behavior.

Publications

Copeland, M.E., and Harris, M. Healing the

Trauma of Abuse: A Women’s Workbook.

New Harbinger Press, 2000.

Fallot, R.D., and Harris, M. The Trauma

Recovery and Empowerment Model

(TREM): Conceptual and practical issues in

a group intervention for women.

Community Mental Health Journal, in

press.

Goodman, L.A., Dutton, M.A., and Harris,

M. Physical and sexual assault prevalence

among episodically homeless women with

serious mental illness. American Journal of

Orthopsychiatry 65(4):468–478, 1995.

Goodman, L.A, Dutton, M.A., and Harris, M.

The relationship between dimensions of violent victimization and symptom severity

among episodically homeless, mentally ill

women. Journal of Traumatic Stress

10(1):51–70, 1997.

Goodman, L., and Fallot, R.D. HIV risk

behavior and poor urban women with serious mental disorders: Association with

childhood physical and sexual abuse.

American Journal of Orthopsychiatry 68

(1):73–83, 1998.

Harris, M. Modifications in service delivery

and clinical treatment for women diagnosed

with severe mental illness who are also the

survivors of sexual abuse trauma. Journal

of Mental Health Administration

21:397–406, 1994.

Harris, M. Treating sexual abuse trauma with

dually diagnosed women. Community

Mental Health Journal 32:4, 1996.

Harris, M., ed. Sexual Abuse in the Lives of

Women Diagnosed with Severe Mental

Illness. Newark, NJ: Harwood Academic

Publishers, 1997.

Harris, M., and the Community Connections

Trauma Work Group. Trauma Recovery

and Empowerment: A Guide for Clinicians

Working with Women in Groups. New

York: The Free Press, 1998.

Harris, M., and Fallot, R.D., eds. Using

Trauma Theory to Design Service Systems.

New Directions for Mental Health Services

Series. San Francisco: Jossey­Bass, 2001.

The Dual Assessment and

Recovery Track (DART)

Contact information

Stanley Sacks, Ph.D., Principal Investigator

Center for the Integration of Research and

Practice

National Development and Research Institutes,

Inc.

71 West 23 Street, 8th Floor

New York, NY 10010

Phone: (212) 845­4648

Fax: (917) 438­0894

446 Emerging Models
Description of intervention

Consistent with findings from the literature, the

Dual Assessment and Recovery Track (DART)

uses the conceptual framework, structure, and

principles of TC treatment found effective for

clients with co­occurring substance abuse and

mental disorders (e.g., fostering personal

responsibility and self­help to cope with life difficulties, use of the peer community as the healing agent and as an essential support for attaining and sustaining recovery, and promoting a

change in lifestyle) and (1) adds critical COD

interventions (“Understanding the Inter­relationship of Mental Health and Substance Abuse

Issues,” “Trauma­Informed Addictions

Treatment”), (2) builds case management skills

to help clients obtain appropriate services, and

(3) improves comorbidity assessment and treatment planning to improve service delivery for

individuals with COD in outpatient substance

abuse treatment settings.

Staffing

DART is provided as a special treatment track

within an Intensive Outpatient Program (IOP)

that the clients attend 3 days a week for 5

hours per day; the IOP is part of a communitybased substance abuse treatment program. One

counselor, trained and experienced in providing treatment services for individuals with cooccurring disorders, provides the DART interventions that are incorporated within the standard IOP treatment program. The DART

counselor reports to the IOP Program

Supervisor. The DART counselor provides the

two specialized weekly treatment groups (cited

above) as well as individual case management

services for 25 clients.

Setting

Gaudenzia, Inc. is a private, not­for­profit

agency that was incorporated in Pennsylvania

in 1968 to provide treatment, prevention, and

other services to those with substance abuse

treatment needs. Gaudenzia employs 350 people, operating 34 programs at 20 facilities, to

provide residential services, traditional outpatient services (e.g., counseling, outreach), and

intensive outpatient services. Target groups

include adults, women with children, the homeless, people who are HIV/AIDS symptomatic,

and those with co­occurring disorders.

The program is located in downtown

Philadelphia on two floors of a recently renovated 8­story facility that houses the outpatient

treatment program, administrative offices, and

several specialized residential treatment programs.

Client characteristics

The DART program is designed to serve men

and women who abuse substances and who

have co­occurring mental disorders. The clients

are primarily minority (75 percent African

American; 12 percent Hispanic) adults, unmarried (71 percent) with an average age of 35.

They are undereducated (on average, 11 years

of education), unemployed (25 percent were

employed in the last year), and 48 percent are

on probation or parole. Cocaine is the major

drug of choice (50 percent of the clients), followed by cannabis (32 percent). Eighty­three

percent of clients report depression at some

time; 24 percent have attempted suicide.

Female clients report a high incidence of physical (76 percent) and sexual abuse (44 percent).

Resources needed for 

implementation

Training. The treatment program is best implemented by a substance abuse counselor trained

and experienced in providing interventions for

individuals with COD. Additionally, since

DART is operated as a specialized treatment

track within a standard outpatient treatment

program, staff cross­training plays a key role in

strengthening the dual diagnosis orientation of

DART. Monthly training seminars were conducted to prepare staff for implementing

DART. The cross­training curriculum included

formal didactic training and technical assistance in program modification for co­occurring

disorders.

Emerging Models 447
Stakeholder Participation. The following principles were utilized to facilitate participation by

key administrative and program staff: program

planning and modification for COD are conducted within agency and system guidelines; all

key stakeholders are involved in planning for

implementation; and a collaborative relationship is fostered between administrative, service, and training staff.

Empirical data

The DART program is currently being evaluated for program effectiveness, costs, and costeffectiveness. The examination of effectiveness

compares DART with the standard substance

abuse outpatient program.

Clients with COD are randomly assigned to

either the DART program model, with

enhanced interventions for individuals with

COD, or to the standard outpatient substance

abuse program. The study employs both GAIN

M90 scales recommended by CSAT to assess

client outcomes across several critical domains

(Substance Use, Physical Health, Mental and

Emotional Health, Environment and Living

Situation, Legal, and Vocational), and two

main standardized psychological scales—Brief

Symptom Inventory, and Beck Depression

Inventory­II (Beck et al. 1996)—to assess outcomes related to psychological, as well as other

areas, of client functioning. Findings from the

evaluation of this program will be applicable to

both TC and non­TC agencies, thereby increasing the impact of the model.

Evaluation of a Treatment

Model for Co-Occurring

Addictive Treatment Stress

Disorder

Contact information

Linda K. Frisman, Ph.D.

Principal Investigator

Connecticut Department of Mental Health and

Addiction Services

Hartford, CT 06134

Phone: (860) 418­6788

Fax: (860) 418­6692

E­mail: frisman@uconnvm.uconn.edu

Description of intervention

This eight­session TARGET model integrates

cognitive–behavioral, motivational enhancement, relational/emotional focuses, and relapse

prevention principles and procedures for trauma recovery and substance abuse recovery. It

provides an alternative to exposure­based

treatment for posttraumatic stress disorder

that is based on recent research and clinical

evidence.

Setting 

Study participants are recruited from three

outpatient substance abuse clinics in

Connecticut: the Morris Foundation in

Waterbury, the Rushford Center in

Middletown, and LMG Inc. in Stamford. These

private, non­profit agencies have extensive

experience working with persons with co­occurring mental disorders. The Morris Foundation,

in addition to outpatient services, operates a

therapeutic shelter, a residential substance

abuse program, and a women and children’s

residential program. Clients receive intense

outpatient services with group therapy and

psychoeducational groups, typically for 4

weeks.

The Rushford Center provides a continuum of

progressive, multi­modal inpatient and outpatient treatment programs for adult men and

448 Emerging Models
women. Services include detoxification, residential programs, day and evening partial hospitalization, and a halfway house.

LMG offers outpatient and residential services

for men, women, youth, and seniors. Services

include detoxification, methadone maintenance,

family treatment, and career development.

Patient characteristics

Study participants are adults (age 18 and over)

with co­occurring substance use and traumarelated disorders. In order to enter the study, a

participant must

1.	 Have a history of exposure to an event(s)

fulfilling the conditions for DSM­IV posttraumatic stress disorder (PTSD) Criterion

A psychological trauma.

2.	 Meet criteria for a substance use disorder.

3.	 Meet DSM­IV criteria for one of the following: (1) PTSD within the past year; or (2)

Disorders of Extreme Stress, Not Otherwise

Specified (DESNOS) plus at least one or

more DSM­IV Axis I or II disorders including: major depressive disorder, dysthymic

disorder, dissociative disorder.

Resources needed for 

implementation

In addition to the cost of the group clinician

and center costs, we needed the following:

• Consultation with trauma expert (first year

of implementation)

• Training in model and cultural competence

• Art supplies for creative arts exercises

• Gift incentives for group participation

• Snacks for groups

• Drug test supplies

Only the time of clinicians and related charges

are reimbursed by most insurance plans; however, we cannot charge because of Medicare

rules regarding research.

Empirical data

This study is still in the field; no findings are

available at this time.

Publications

The TARGET manual is now available from

the above address.

Homelessness Prevention TC

for Addicted Mothers

Contact information

Jo Ann Sacks, Ph.D., Principal Investigator

Center for the Integration of Research &

Practice

National Development and Research Institutes,

Inc.

71 W 23rd St., 8th Floor

New York, NY 10010

Tel: (212) 845­4648

Fax: (917) 438­0894

Description of the 

intervention

The program, for mothers and their children,

uses TC principles and methods to address the

problem of substance abuse, to provide a foundation for a full personal recovery or change,

and to furnish an environment within which

homelessness prevention interventions occur.

The specific homelessness prevention activities

include 14 distinctive interventions that

address family preservation, work, housing stabilization, and building a supportive community. The mothers progress through program

stages and typically move from residential to

permanent housing.

Staffing

The residential program is staffed 24 hours a

day, 7 days a week, with a combination of

supervisors, counselors, and house managers.

Three staff members, including at least one

supervisor, are present during peak programEmerging Models 449
ming hours (9 a.m. to 9 p.m.); two staff members are present overnight. The Director and

Clinical Supervisor are available for consultation on an emergency pager system when they

are not on­site. The Prevention Specialist provides special parenting skills training groups on

weekdays and substance abuse prevention

groups for children during the family education

activities on Sunday, enriching the staffing at

those times. The Transitional program is

staffed with one counselor/case manager for

approximately 20 individuals. A Prevention

Specialist and Child Care Worker staff the

Child Care program with the help of two or

three mothers who are assigned to participate

in the Child Care program each day as part of

their parenting training.

Setting

Gaudenzia is a private, not­for­profit TC­oriented agency, incorporated in Pennsylvania in

1968 to provide treatment, prevention and

other services to people with substance abuse

and related problems. Two of Gaudenzia’s 34

programs, New Image in Philadelphia and

Kindred House in West Chester, were developed in 1989 (in cooperation with the City of

Philadelphia Health Department and the U.S.

Public Health Service) as programs to prevent

homelessness among those homeless, substanceabusing women who were pregnant and/or who

were parenting at least one child. Each mother

entering the program is allowed to bring up to

two of her dependent children with her.

Both program sites share similar physical

design elements, including: bedroom space

occupied by two or three mothers and their

young children; gender­specific dormitory bedrooms shared by up to four older children;

communal dining and recreational space; infant

and pre­school nursery/day care space; group

meeting rooms and office space for administrative work, and individual counseling.

Client characteristics

The program is for homeless substance­abusing

mothers (most with COD) and their children.

The clients can be characterized as predominantly minorities (80 percent), average age 33,

never married (66 percent), from broken

homes (71 percent) and with less than a high

school education (53 percent). The women

reported three children on average, with only

one child having primary residence with the

mother at baseline. The women show a history

of drug use (97 percent), arrest (76 percent),

homelessness 62 percent), and moderate levels

of psychological symptoms, as indicated by

average Beck Depression Inventory (BDI)

scores of 17.69 (SD=10.2) and average

Symptom Check­List 90­Revised Global

Severity Index (SCL 90­R) scores of 65.07

(SD=10.27).

Resources needed for 

implementation

Follow six principles for successful program

implementation.

1. Work within the guidelines of agency and

system.

2. Involve stakeholders in the project.

3. Use a strategic program planning approach

and involve all key staff in program planning and refinement.

4. Employ active training and technical assistance during the refinement and implementation of new elements.

5. Review program fidelity periodically.

6. Develop ownership and a firm collaborative

relationship among service, training, and

evaluation staff.

Empirical data

This women’s therapeutic community enhanced

with programming focused on the prevention of

homelessness was evaluated using a quasi­experimental design. Propensity analysis was used to

select a subgroup in which the Experimental (E)

and Comparison (C) participants were comparable. At the domain level, statistically significant

450 Emerging Models
relative improvement for the E group was found

in psychological dysfunction and health. In the

former domain, significant improvement was

found on two standard psychological inventories

measuring symptoms, for example, depression.

In the latter domain, significant improvements

included ratings of the women’s health and

adherence to medication regimens. No significant difference was found at the domain levels of

family preservation and housing stabilization,

but the results were mixed over specific outcomes in each; e.g., mothers in the E group

showed better outcomes on the number of children residing with the mother and the number

of children for whom the mother assumes financial responsibility. These results show the feasibility of extending the range and applicability of

the TC model to address the specific problems of

homeless mothers with COD and their children.

Publications

Sacks, J.Y., Sacks, S., Harle, M., and De

Leon, G. Homelessness prevention therapeutic community (TC) for addicted mothers. In: Conrad, K.J., Matters, M.D.,

Hanrahan, P., and Luchins, D.J. (eds).

Homelessness prevention in treatment of

substance abuse and mental illness: Logic

models and implementation of eight

American projects. Alcoholism Treatment

Quarterly 17(1/2):33–51, 1999.

Sacks, S., Sacks, J.Y., Bernhardt, A.I.,

Harle, M., and De Leon, G. Homelessness

Prevention TC for Addicted Mothers: A

Program Manual. Center for Mental Health

Services (CMHS)/Center for Substance

Abuse Treatment (CSAT), Rockville, MD,

GFA SM 96­01, CFDA #93.230—Grant #1

UD9 SM51969­01. New York, NY:

NDRI/CTCR, 1997.

Sacks, S., Sacks, J.Y., McKendrick, K.,
 

Pearson, F.S., and Banks, S. TC for
 

Homeless, Addicted Mothers and Their
 

Children: Change in Psychological and
 

Health Status, Family Re­integration and
 

Housing. Journal of Behavioral Health
 

Services & Research (in review).
 

Improving Services for

Substance Abusers With

Comorbid Depression

Contact information

Joe Horton, M.S.W., LCSW, Project Manager

Washington University

One Brookings Drive

St. Louis, MO 63130

Phone: (314) 286­2499

Fax: (314) 286­2265

E­mail: jch1@gwbmail.wustl.edu

Description of intervention

The overall goal of the study is to document the

effectiveness of a program to increase the identification of depression among people who

abuse substances and to improve the treatment

services offered to people with these complex

co­occurring conditions. This goal is being

addressed by conducting in­person psychiatric

assessments on 500 consecutive adult admissions to the Chestnut Health Systems substance

abuse treatment programs in Madison County,

MO, using the Diagnostic Interview Schedule

IV (DIS).

Setting

The program is located in rural Madison

County, MO. Illinois Chestnut Health System is

a community mental health agency.

Client characteristics

The populations are diverse—probation/

parole, Department of Family Services,

Department of Corrections, and public and

private programs. This is primarily a population with substance use disorders, and 27 percent are currently diagnosed with depression.

Emerging Models 451
Resources needed for 

implementation

Chestnut Health System is self­supportive

through grants and State funding. Most barriers have been overcome by the staff from

Washington University working closely with the

Chestnut staff to solve problems on a weekly

basis.

Empirical data

Outcome measures have not been evaluated as

there is a 6­month and 12­month followup.

Currently only baseline data are available,

which do not lead to outcome measures.

Publications

Compton, W. Improving treatment services for

substance abusers with comorbid depression.

Journal of Substance Abuse Treatment, 2001.

Multi-Disciplinary Mental

Health and Substance Abuse

Treatment

Contact information

Robert Calsyn, Ph.D., Principal Investigator

University of Missouri

8001 Natural Bridge Road

St. Louis, MO 63121

Phone: (314) 516­5421

Fax: (314) 516­5210

E­mail: robert_calsyn@umsl.edu

Description of intervention

Multi­disciplinary mental health and substance

abuse treatment team with case management to

coordinate HIV/AIDS primary care and other

services. Study participants randomly assigned

to integrated services or care­as­usual, which

consists of limited availability of mental health

and substance abuse services, and case management. To date, 159 individuals are enrolled

in the study. Results are not yet available.

Setting

Community­based integrated mental health,

substance abuse, and case management services provider.

Client characteristics

Multiply diagnosed individuals recruited from

metropolitan area, Ryan White­funded case

management providers.

Resources needed for 

implementation

Keys to successful implementation include (1)

steering committee of target populations, Ryan

White program staff, and other service

providers; (2) assertive community treatment

team that coordinates care of triple­diagnosed

clients.

Orange County Needs-Based

Treatment Intervention for

Mothers’ Engagement (ON

TIME) Project

Contact information

Nancy K. Young, Ph.D., Co­Principal

Investigator

Children and Family Futures

4940 Irvine Blvd., Suite 202

Irvine, CA 92620

Phone: (714) 505­3525

Fax: (714) 505­3626

E­mail: nkyoung@cffutures.com

Description of intervention

The ON TIME project, a partnership of

researchers and public and private agencies, is

designed to address the need for timely intervention with women affected by substance

abuse and child welfare. The goals of the project are: (1) to assess the ability of alcohol and

other drug (AOD) and social service systems to

respond to the new timelines of the Adoption

452 Emerging Models
and Safe Families Act (ASFA) among women

who need AOD treatment; (2) to test the effectiveness of outreach, intervention, engagement,

and re­engagement strategies with women who

abuse substances under ASFA; and (3) to measure four primary outcomes: decrease substance use, increase treatment compliance,

increase family stability, and increase participation in employment activities. This intervention is provided by outreach Recovery Mentors

who are extensively trained in Motivational

Enhancement Therapy and have personal

experience in recovery and social service systems.

Setting

The ON TIME project is a county­wide program serving women in Orange County,

California. The project is a collaboration

among organizations in the county that serve in

the best interests of children and their families.

Orangewood Children’s Foundation is the

grantee, providing administrative support to

the project through its role as a community

leader on children’s issues. Children and

Family Futures is a non­profit organization

that offers strategic planning and evaluation to

local and State entities that provide services to

children whose parents have substance abuse

issues. Southern California Alcohol and Drug

Programs run several substance abuse treatment agencies in surrounding areas and employ

the Recovery Mentors. Finally, UCLA Drug

Abuse Research Center provides the analysis of

data involving follow­up interviews. These

agencies work in collaboration with Children

and Family Services, the county child welfare

organization. The Recovery Mentors are outstationed at the dependency court. They provide Motivational Enhancement Therapy and

serve as liaisons to treatment providers in the

community.

Client characteristics

Women over the age of 18 are eligible for the

project if they have substance abuse allegations

in the dependency court petition. These women

have a multitude of issues co­occurring with

substance use such as mental health issues,

domestic violence involvement, criminal backgrounds, and welfare and employment issues.

Resources needed for 

implementation

The key to implementation for ON TIME was

the need for a communication protocol among

partner agencies. Due to confidentiality1 concerns, as well as the research protocol involving

human subjects, clients sign a consent form for

participation and to allow communication

between social services, attorney groups, and

the ON TIME project staff. The Recovery

Mentors were extensively trained in

Motivational Enhancement Therapy techniques, the Addiction Severity Index, ASAM

Patient Placement Criteria, and other tools for

intervention. Resources required for implementation include the curriculum and training

materials for these tools as well as purchase of

the tools themselves. It was essential in the

recruitment of Recovery Mentors that they

reflect the cultural diversity of the community.

One of the mentors is bilingual in Spanish,

reflecting the 50 percent Hispanic/Latino population in the county, and all four mentors are

women in recovery from addiction.

Empirical data

Preliminary findings include: significantly

fewer ON TIME mothers had positive urine

toxicology tests between the Detention Hearing

and the 21­day hearing than the comparison

group of mothers who did not receive these services; a higher percentage of ON TIME women

entered treatment prior to their 6­month

1

Confidentiality is governed by the Federal “Confidentiality of Alcohol and Drug Abuse Patient Records” regulations (42

CFR Part 2) and the federal “Standards for Privacy of Individually Identifiable Health Information” (45 CFR Parts

160 and 164).

Emerging Models 453
review than the comparison group. Among current ON TIME clients, they significantly

increased their readiness to make lifestyle

changes in the first 3 weeks of participation; 86

percent and 82 percent of the clients had follow­up interviews at 3 and 9 months; mothers

reported a significant decrease in illicit substance use and alcohol consumption at the 3­

and 9­month interviews; and the ASI scores significantly decreased between baseline and 9­

month interviews in all areas except employment.

Project SPIRIT: Seeking the

Pathways Into Recovering

Integrated Treatment

Contact information

Roy M. Gabriel, Ph.D.

Principal Investigator

RMC Research Corporation

522 SW Fifth Avenue, Suite 1407

Portland, OR 97024

E­mail: roy_gabriel@rmccorp.com

Description of intervention

Project SPIRIT is an evaluation study designed

to document and demonstrate the effectiveness

of integrated treatment approaches for treating

persons with co­occurring substance abuse and

mental health problems. Study participants are

naturalistically or quasi­randomly assigned to

one of six treatment agencies depending on the

recruitment source. Study participants are currently being recruited from central locations

(i.e., family health clinic, detoxification agency)

that subsequently refer these individuals to

treatment and directly from the participating

treatment agencies themselves. Each participating agency has been categorized as an integrated treatment program, a COD track program,

or a nonspecialized program based on preliminary process information collected from each

site.

Setting

The agencies involved in the study are all located in the Portland (Oregon) metropolitan area.

They range from a small SA/MH treatment service­only agency to a large, multi­program

social service agency dedicated to meeting the

array of needs of the city’s most indigent, disadvantaged individuals.

Patient characteristics 

All potential study clients are screened using

the Millon Clinical Multiaxial Inventory III

(MCMI). Client eligibility is defined as having a

clinically diagnosed alcohol or drug dependence or addiction treatment determined by a

certified clinician and a suspected Axis I or

Axis II mental health program detected by

MCMI. The agencies range from 50 percent to

77 percent of their COD clients evidencing Axis

I severe clinical syndromes.

Resources needed for 

implementation

MH services are covered in a managed care

system that differs from the managed care system that governs substance abuse services. This

poses serious obstacles to providers trying to

treat individuals with co­occurring SA and MH

disorders.

Empirical data

Baseline data collection is complete. Documentation of the three treatment approaches is

ongoing and includes provider surveys,

provider interviews, client focus groups, and

document reviews. The baseline sample size is

N=280, split among the three models under

study: Integration (n=109), serial/parallel

(n=98), and no MH services (n=73). As of

September 1, 2002, the 6­month follow­up

response rate is approximately 86 percent.

454 Emerging Models
Publications

A progress report on Project SPIRIT activities

will include the evolution of the client recruitment strategy to include multiple sources, modifications to the original study design and analysis plan, a detailed description of the screening process, current description of the study

population, experiences working with health

clinic physicians, and preliminary results from

the provider survey. Current project reports

include a Study Methods Report, detailing the

design and instrumentation of the study; and a

Baseline Report, characterizing the sample in

terms of their demographics, treatment history,

alcohol and drug use, MH symptomatology,

and criminal justice history.

The Rural HIV/AIDS, Substance

Abuse, Mental Health

Outcomes Study

Contact information

Kate Whettan­Goldstein, Ph.D., M.P.H.,

Principal Investigator

Center for Health Policy, Law & Management

Duke University

125 Old Chemistry Building, Box 90253

Durham, NC 27708

Phone: (919) 684­8012

E­mail: kwg@hpolicy.duke.edu

Rachel Stevens, M.P.H., Project Director

Phone: (919) 684­3368

Fax: (919) 681­9034

E­mail: rstevens@hpolicy.duke.edu

Description of intervention

Twelve months of intensive outpatient mental

health and substance abuse counseling in conjunction with rural case manager contracts and

transportation services to promote treatment

adherence. Subgroups of study participants

compared across time; care­as­usual for those

who do not engage in intervention services consists of the limited amount of counseling available at the HIV/AIDS clinics.

Setting

Two integrated outpatient mental health and

substance abuse service providers linked to

nearby HIV/AIDS primary care clinics. One is

based in Durham, NC (The Duke Addictions

Program), the other in Fayetteville, NC (county mental health agency).

Client characteristics

Multiply diagnosed individuals from rural

counties who receive care from one of the

HIV/AIDS clinics.

Resources needed for 

implementation

This model program receives funding from

NIDA, SAMHSA, HRSA, NIMH, and NIAAA.

All of our staff have experience in a variety of

settings in points of diverse backgrounds. Our

main barrier is transportation costs, which are

continually being addressed by various AIDSrelated service agencies. The addition of a

recruitment and retention specialist who follows up on contacts has greatly increased the

retention rate.

Trauma Adaptive Recovery

Group Education and Therapy

for Addiction Recovery

(TARGET-AR)

Contact information

Julian Ford, Ph.D., Co­Principal Investigator

Department of Psychiatry

University of Connecticut Health Center

263 Farmington Avenue

Farmington, CT 06030

Phone: (860) 679­2730

Fax: (860) 679­4326

E­mail: ford@psychiatry.uchc.edu

Emerging Models 455
Description of intervention

This nine­session model integrates neurobiological, developmental, cognitive–behavioral,

motivational enhancement, relational/emotion

focuses, and relapse prevention principles and

procedures for trauma recovery and substance

abuse recovery. It provides an alternative to

exposure­based treatment for PTSD that is

based on recent research and clinical evidence.

Participants learn a structured set of skills for

managing traumatic stress symptoms in their

current life, described by the acronym “FREEDOM” (Focusing to reduce anxiety and

increase mental alertness; Recognizing specific

stress triggers; identifying primary Emotions;

Evaluating primary thoughts/self­statements;

Defining an organizing personal goal; identifying one Option that represents a successful step

toward that goal that the individual actually

accomplished during a current stressful experience; recognizing how that option had the

added benefit of Making a contribution), by

reflecting the person’s core values and making

a difference in others’ lives. The model assists

participants in understanding the effects of

trauma on the body, emotions, mind, relationships, and spirituality, and in using the FREEDOM skills to manage current stressors in ways

that enable the person to shift away from “survival” coping to productive living. Participants

are encouraged to focus on dealing with the

impact that trauma experiences have had on

their current lives rather than recounting

detailed trauma memories, and the FREEDOM

skills are used as a way to enable participants

to examine trauma memories in a contained

manner—and only if the participant feels that

this would be helpful in dealing with current

stressors. Most participants choose to examine

trauma memories using the FREEDOM skills

with an individual counselor rather than in the

group, or in order to share a specific limited

aspect of a key trauma memory in the group.

The TARGET model has the following theoretical/clinical base: Recovery from trauma is possible when a person is able to shift from living

in “survival” mode to focusing on personal

growth and effectiveness in intimate, family,

friendship, and work relationships. Recovery is

not based on “getting through” or becoming

“desensitized” to trauma memories, but on

having access to a support system and a way of

making fully informed life decisions that fundamentally shift a person’s bodily processes and

mindset from surviving trauma to personal

growth and development. Recovery is unique

for each gender and each individual, but

always involves three basic changes that occur

gradually: isolation, betrayal, and abandonment, gradually changing to trust, mutuality,

and engagement within safe, reliable, and emotionally sustaining relationships. Terror, hypervigilance, dissociation, and powerlessness gradually change to a realistic sense of personal

effectiveness with a clear focus on immediate

emotions, thoughts, and goals in each experience. Emotional numbing, spiritual alienation,

and hopelessness gradually shift to involvement, self­esteem, faith, and hope as the person becomes able to recognize how she or he

actually is living according to her or his true

values and making a unique contribution to the

safety and well­being of other people.

Setting

Study participants are recruited from three

outpatient substance abuse clinics: the Morris

Foundation in Waterbury, and The Connection

and Rushford Center in Middletown. These

private, non­profit agencies have extensive

experience working with persons with co­occurring mental disorders. The Morris Foundation,

in addition to outpatient services, operates a

therapeutic shelter, a residential substance

abuse program, and a women and children’s

residential program. Clients receive intense

outpatient services with group therapy and

psychoeducational groups, typically for 4

weeks.

The Rushford Center provides a continuum of

progressive, multi­modal inpatient and outpatient treatment programs for adult men and

women. Services include detoxification, residential programs, day and evening partial hospitalization, and a halfway house.

456 Emerging Models
The Connection is a statewide agency operating

over 30 separate programs. It offers assistance

with a wide variety of behavioral and social

problems, including homelessness, sex offenses,

problem gambling, HIV­related needs, child

abuse/neglect, and substance abuse.

Client characteristics

Study participants are adults (age 18 and over)

with co­occurring substance use and traumarelated disorders. In order to enter the study, a

participant must:

• Have a history of exposure to an event(s) fulfilling the conditions for DSM­IV PTSD

Criterion A psychological trauma.

• Meet criteria for a substance use disorder.

• Meet DSM­IV criteria for one of the following: (1) PTSD within the past year, or (2)

Disorders of Extreme Stress, Not Otherwise

Specified plus at least one or more DSM­IV

Axis I or II disorders including major depressive disorder, dysthymic disorder, and dissociative disorder.

Resources needed for 

implementation

In addition to the cost of the group clinician

and center costs, the following were needed:

• Consultation with trauma expert (weekly

during first year of implementation)

• Training in model and cultural competence

• Art supplies for creative arts exercises

• Incentives for group participation

• Snacks for groups

• Drug test supplies

Only the time of clinicians and related charges

are reimbursed by most insurance plans; however, Medicare rules regarding research prevents the program from charging clients.

Empirical data

TARGET­RMI is in the second phase of a qualitative evaluation at Capitol Region Mental

Health Center, with groups ongoing for hearing­impaired women, hearing women, hearingimpaired men, and hearing men. Between

March and June 2002, three additional community mental health centers and one additional addiction agency received training and began

1 year of clinical pilot work in preparation for

a multi­site controlled trial in the mental health

sector to complement and extend the 3­year

randomized controlled trial (separate men’s

and women’s groups). The three addiction

agencies now underway are under the auspices

of the Co­Occurring Disorders study. Both versions of TARGET are being pilot tested by clinicians in Holland who were trained (April 2000)

by Dr. Ford; a controlled clinical trial is scheduled to begin later this year.

Publications

The TARGET manual will be available soon; it

is currently being modified. It is being translated into Spanish and has been translated into

Dutch.

Programs

Following is a full listing of programs that were

asked to provide more information for this

appendix. The models described in this

appendix came from the responses that were

received.

• Orange County Needs­Based Treatment

Intervention for Mothers’ Engagement (ON

TIME) Project

• Access to Medical and Substance Abuse

Treatment in the Setting of Prescribing

Syringes to Active Injection Drug Users

• Case Management for Rural Substance Abuse

• Improving Services for Substance Abusers

With Comorbid Depression

• Rural HIV/AIDS, Substance Abuse, Mental

Health Outcomes Study

Emerging Models 457
• Multi­Disciplinary Mental Health and

Substance Abuse Treatment

• Trauma Adaptive Recovery Group Education

and Therapy for Addiction Recovery (TARGET­AR)

• Managing Co­Occurring Disorders in an

Opioid Agonist Setting

• College Drinking

• Outreach­Assisted Case Management: A

Model for HIV and STD Prevention

• Linkages of Primary Care Patients to

Substance Abuse Treatment

• Evaluation of ADMIRE Plus Program for

Co­Occurring Disorders

• Evaluation of a Treatment Model for CoOccurring Addictive and Traumatic Stress

Disorders

• Managing Co­Occurring Disorders in

Methadone Clinics

• Increasing Substance Abuse Treatment

Compliance for Persons With Traumatic

Brain Injury

• Project SPIRIT: Seeking Pathways Into

Receiving Integrated Treatment

• Dual Assessment and Recovery Track

(DART)

• Facilitating Substance Abuse Treatment for

HIV Patients

• Linking Female Sex Workers to Substance

Abuse Treatment

• Multiple Diagnoses Cost Study and

Intervention Study

• Project to Reduce Overutilization of

Detoxification services (PROUD)

• Integrated Service Agency (ISA) Home Visit

Family Intervention Model

• Boley Homelessness Prevention Project

• Gaudenzia

• The Housing Continuum

• Representative Payee­Money Management

Program

• Consumer Preference Independent Living

(CPIL)

• Project HOME (Housing, Opportunities,

Medical care, and Education)

458 Emerging Models
Appendix F:

Common Medications

for Disorders

This appendix contains the Pharmacological Management section from

TIP 9, Assessment and Treatment of Clients With Coexisting Mental

Illness and Alcohol and Other Drug Abuse (Center for Substance Abuse

Treatment 1994a, pp. 91–94). This section is followed by an adaptation

of the text of Psychotherapeutic Medications 2004: What Every

Counselor Should Know, a publication of the Mid­America Addiction

Technology Transfer Center. Many of the terms are highly technical;

however, to define them is beyond the scope of the TIP. The counselor

can understand the fundamental information contained in each section

without knowing the definition of every term. This appendix provides

the counselor with a handy reference on various psychotropic medications and their use.

Pharmacologic Risk Factors 

Addiction is not a fixed and rigid event. Like mental disorders, addiction

is a dynamic process, with fluctuations in severity, rate of progression,

and symptom manifestation and with differences in the speed of onset.

Both disorders are greatly influenced by several factors, including genetic susceptibility, environment, and pharmacologic influences. Certain

people have a high risk for these disorders (genetic risk); some situations

can evoke or help to sustain these disorders (environmental risk); and

some drugs are more likely than others to cause psychiatric or substance

use disorder problems (pharmacologic risk).

Pharmacologic effects can be therapeutic or detrimental. Medication

often produces both effects. Therapeutic pharmacologic effects include

the indicated purposes and desired outcomes of taking prescribed medications, such as a decrease in the frequency and severity of episodes of

depression produced by antidepressants.

Detrimental pharmacologic effects include unwanted side effects such as

dry mouth or constipation resulting from antidepressant use. Side effects

459
perceived as noxious by clients may decrease

their compliance with taking the medications as

directed.

Some detrimental pharmacologic effects relate

to abuse and addiction potential. For example,

some medications may be stimulating, sedating,

or euphorigenic and may promote physical

dependence and tolerance. These effects can

promote the use of medication for longer periods and at higher doses than prescribed.

Thus, prescribing medication involves striking

a balance between therapeutic and detrimental

pharmacologic effects. For instance, therapeutic antianxiety effects of the benzodiazepines

are balanced against detrimental pharmacologic effects of sedation and physical dependency.

Similarly, the desired therapeutic effect of

abstinence from alcohol is balanced by the possibility of damage to the liver from prescribed

disulfiram (Antabuse).

Side effects of prescription medications vary

greatly and include detrimental pharmacologic

effects that may promote abuse or addiction.

With regard to clients with co­occurring disorders, special attention should be given to detrimental effects, in terms of (1) medication compliance, (2) abuse and addiction potential, (3)

substance use disorder relapse, and (4) psychiatric disorder relapse (Ries 1993).

Psychoactive Potential

Not all psychiatric medications are psychoactive. The term psychoactive describes the ability of certain medications, drugs, and other

substances to cause acute psychomotor effects

and a relatively rapid change in mood or

thought. Changes in mood include stimulation,

sedation, and euphoria. Thought changes can

include a disordering of thought such as delusions, hallucinations, and illusions. Behavioral

changes can include an acceleration or retardation of motor activity. All drugs of abuse are by

definition psychoactive.

In contrast, certain nonpsychoactive medications such as lithium (Eskalith) can, over time,

normalize the abnormal mood and behavior of

clients with bipolar disorder. Because these

effects take several days or weeks to occur, and

do not involve acute mood alteration, it is not

accurate to describe these drugs as psychoactive, euphorigenic, or mood altering. Rather,

they might be described as mood regulators.

Similarly, some drugs, such as antipsychotic

medications, cause normalization of thinking

processes but do not cause acute mood alteration or euphoria.

However, some antidepressant and antipsychotic medications have pharmacologic side

effects such as mild sedation or mild stimulation. Indeed, the side effects of these medications can be used clinically. Physicians can use

a mildly sedating antidepressant medication for

clients with depression and insomnia, or a

mildly stimulating antipsychotic medication for

clients with psychosis and hypersomnia or

lethargy (Davis and Goldman 1992). While the

side effects of these drugs include a mild effect

on mood, they are not euphorigenic.

Nevertheless, case reports of misuse of nonpsychoactive medications have been noted, and

use should be monitored carefully in clients

with co­occurring disorders.

While psychoactive drugs are generally considered to have high risk for abuse and addiction,

mood­regulating drugs are not. A few other

medications exert a mild psychoactive effect

without having addiction potential. For example, the older antihistamines such as doxylamine (Unisom) exert mild sedative effects, but

not euphoric effects.

Reinforcement Potential

Some drugs promote reinforcement, or the

increased likelihood of repeated use.

Reinforcement can occur by either the removal

of negative symptoms or conditions or the

amplification of positive symptoms or states.

For example, self­medication that delays or

prevents an unpleasant event (such as withdrawal) from occurring becomes reinforcing.

Thus, using a benzodiazepine to avoid alcohol

withdrawal can increase the likelihood of continued use. Positive reinforcement involves

460 Common Medications for Disorders
strengthening the possibility that a certain

behavior will be repeated through reward and

satisfaction, as with drug­induced euphoria or

drug­induced feelings of well­being. A classic

example is the pleasure derived from moderate

to high doses of opioids or stimulants. Drugs

that are immediately reinforcing are more likely to lead to psychiatric or substance use problems.

Tolerance and Withdrawal

Potential

Long­term or chronic use of certain medications can cause tolerance to the subjective and

therapeutic effects and prompt dosage increases to recreate the desired effects. In addition,

many drugs cause a well­defined withdrawal

phenomenon after the cessation of chronic use.

Clients’ attempts to avoid withdrawal syndromes often lead them to additional drug use.

Thus, drugs that promote tolerance and withdrawal generally have higher risks for abuse

and addiction.

A Stepwise Treatment

Model

As can be seen, there are pharmacologic as well

as hereditary and environmental factors that

influence the development of substance use disorders. All of these factors should be considered before prescribing medication, especially

when the client is at high risk for developing a

substance use disorder. High­risk clients

include people with both psychiatric and substance use disorders, as well as clients with a

psychiatric disorder and a family history of

substance use disorders.

One aspect of this issue relates to the pharmacologic profile of certain medications that are

used in the treatment of specific psychiatric

disorders. For instance, many medications

used to treat symptoms of depression and psychosis are not psychoactive or euphorigenic.

However, many of the medications used to treat

symptoms of anxiety, such as the benzodiazepines, are psychoactive, reinforcing, have

potential for tolerance and withdrawal, and

have an abuse potential, especially among people who are at high risk for substance use disorders. Other antianxiety medications, such as

buspirone (BuSpar), are not psychoactive or

reinforcing and have low abuse potential, even

among people at high risk.

Thus, decisions about whether and when to

prescribe medication to a high­risk client

should include a risk­benefit analysis that considers the risk of medication abuse, the risk of

undertreating a psychiatric problem, the type

and severity of the psychiatric problem, the

relationship between the psychiatric disorder

and the substance use disorder for the individual client, and the therapeutic benefits of

resolving the psychiatric and substance abuse

problems.

For example, the early and aggressive medication of high­risk clients who have severe presentations of psychotic depression, mania, and

schizophrenia is often necessary to prevent further psychiatric deterioration and possible

death. For these clients, rapid and aggressive

medication can shorten the length of the psychiatric episodes. In contrast, prescribing benzodiazepines to high­risk clients with similarly

severe anxiety involves a substantial risk of

promoting or exacerbating a substance use disorder. For these high­risk clients, the use of

psychoactive medication should not be the first

line of treatment. Rather, for some high­risk

clients, treatment efforts should involve a stepwise treatment model that begins with conservative approaches and progressively becomes

more aggressive if the treatment goals are not

met (Landry et al. 1991a). For example, the

stepwise treatment model for treating high­risk

clients with anxiety disorders may involve three

progressive levels of treatment: (1) nonpharmacologic approaches when possible; (2) nonpsychoactive medication when nonpharmacologic

approaches are insufficient; and (3) psychoactive medications when other treatment

approaches provide limited or no relief

(Landry et al. 1991a).

Common Medications for Disorders 461
Nonpharmacologic

Approaches

Depending on the psychiatric disorders and

personal variables, numerous nonpharmacologic approaches can help clients manage all or

some aspects of their psychiatric disorders.

Examples include psychotherapy, cognitive

therapy, behavioral therapy, relaxation skills,

meditation, biofeedback, acupuncture, hypnotherapy, self­help groups, support groups,

exercise, and education.

Nonpsychoactive

Pharmacotherapy

Some medications are not psychoactive and do

not cause acute psychomotor effects or euphoria. Some medications do not cause psychoactive or psychomotor effects at therapeutic doses

but may exert limited psychoactive effects at

high doses (often not euphoria, but sometimes

dysphoria).

For practical purposes, all of these medications

can be described as nonpsychoactive, since the

psychoactive effect is not prominent.

Medications used in psychiatry that are not

euphorigenic or significantly psychoactive

include but are not limited to the azapirones

(for example, buspirone), the amino acids,

beta­blockers, antidepressants, monoamine

oxidase inhibitors, antipsychotics, lithium,

antihistamines, anticonvulsants, and anticholinergic medications.

Psychoactive

Pharmacotherapy

Some medications can cause significant and

acute alterations in psychomotor, emotional,

and mental activity at therapeutic doses. At

higher doses, and for some clients, some of

these medications can also cause euphoric reactions. Medications that are potentially psychoactive include opioids, stimulants, benzodiazepines, barbiturates, and other sedative­hypnotics.

Stepwise Treatment Principles

One of the emphases of stepwise treatment is to

encourage nondrug treatment strategies for

each emerging symptom before medications are

prescribed. Nondrug treatment strategies alone

are inappropriate for acute and severe symptoms of schizophrenia and mood disorders, but

nondrug strategies do have their place in the

treatment of virtually any psychiatric problem

and may provide partial or total relief of some

symptoms related to severe psychiatric disorders. For example, relaxation therapy can minimize or eliminate somatic symptoms of anxiety

that may accompany an agitated depression.

A second emphasis of stepwise treatment is to

encourage the use of medications that have a

low abuse potential. This conservative

approach must be balanced against other therapeutic and safety considerations in acute and

severe conditions, such as psychosis or mania.

On the other hand, a conservative approach is

not the same as undermedication of psychiatric

problems. Undermedication often leads to psychiatric deterioration and may promote substance abuse relapse. There should be a balance between effective treatment and safety.

A third emphasis of stepwise treatment is to

encourage the idea that different treatment

approaches should be viewed as complementary, not competitive. For example, if psychotherapy or group therapy does not provide

complete relief from a situational depression

(such as prolonged grief), then antidepressants

should be considered as an adjunct to the psychotherapy, but not as a substitute for psychotherapy.

In practice, treatment providers often use a

combination of drug and nondrug strategies.

This practice includes medication to treat the

acute manifestations of the disorder while the

individual learns long­term management strategies. For example, an individual may be prescribed nonpsychoactive buspirone to reduce

anxiety symptoms while learning stress reduction techniques and attending group therapy.

462 Common Medications for Disorders
These guidelines are broad, general, and more

applicable to chronic than to acute psychiatric

problems. Also, these guidelines have limited

application to severe psychiatric problems.

Psychotherapeutic

Medications 2004:

What Every Counselor

Should Know

Following is the text of Psychotherapeutic

Medications 2004: What Every Counselor

Should Know, a publication of the MidAmerica Addiction Technology Transfer Center

(MATTC), which was adapted for this TIP.

This brochure is updated annually and is available via the MATTC Web site at

http://www.attcnetwork.org/regcenters/index_

midamerica.asp.

The brochure addresses the following areas:

• Antipsychotics/Neuroleptics

• Antimanic Medications

• Antidepressant Medications

• Antianxiety Medications

• Stimulant Medications

• Narcotic and Opioid Analgesics

• Antiparkinsonian Medications

• Hypnotics

• Addiction Treatment Medications

For physicians desiring a more in­depth discussion regarding the challenges of treating specific population groups with substance use disorders (e.g., homeless, older adults, people with

HIV/AIDS or hepatitis, pregnant or nursing

women, etc.), which includes medication compliance, adverse drug interactions, and relapse

with the use of potentially addictive medications, readers are referred to the current edition of the American Society of Addiction

Medicine’s (ASAM’s) Principles of Addiction

Medicine, Third Edition (ASAM 2003).

Tips For Communicating With

Physicians About Clients and

Medication

Send a written report

The goal is to get your concerns included in the

client’s medical record. When information is in

a medical record, it is more likely to be acted

on. Records of phone calls and letters are

rarely placed in the chart (readers may go to

http://www.attcnetwork.org/regcenters/index_

midamerica.asp to download a sample

form).

Make it look like a report—

and be brief

Include date of report, client name, and Social

Security Number. Most medical consultation

reports are one page. Longer reports are less

likely to be read. Include and prominently

label sections:

• Presenting Problem

• Assessment

• Treatment and Progress

• Recommendations and Questions

Keep the tone neutral

Provide details about the client’s use or abuse

of prescription medications. Avoid making

direct recommendations about prescribed medications. Allow the physician to draw his or her

own conclusions. This will enhance your

alliance with the physician and makes it more

likely he or she will act on your input.

Talking with clients about

their medication

Untreated psychiatric problems are a common

cause for treatment failure in substance abuse

treatment programs. Supporting clients with

mental illness in continuing to take their psychiatric medications can significantly improve

substance abuse treatment outcomes.

Common Medications for Disorders 463
Getting started

Take 5–10 minutes every few sessions to go over

these topics with your clients:

• Remind them that taking care of their mental

health will help prevent relapse.

• Ask how their psychiatric medication is helpful.

• Acknowledge that taking a pill every day is a

hassle.

• Acknowledge that everybody on medication

misses taking it sometimes.

• Do not ask if they have missed any doses,

rather ask, “How many doses have you

missed?”

• Ask if they felt or acted different on days

when they missed their medication.

• Was missing the medication related to any

substance use relapse?

• Without judgment, ask “Why did you miss

the medication? Did you forget, or did you

choose not to take it at that time?”

For clients who forgot, ask

them to consider the following strategies

• Keep medication where it cannot be missed:

with the TV remote control, near the refrigerator, or taped to the handle of a toothbrush. Everyone has two or three things they

do everyday without fail. Put the medication

in a place where it cannot be avoided when

doing that activity, but always away from

children.

• Suggest they use an alarm clock set for the

time of day they should take their medication. Reset the alarm as needed.

For clients who admit to

choosing not to take their

medication

• Acknowledge they have a right to choose

NOT to use any medication.

• Stress that they owe it to themselves to make

sure their decision is well thought out. It is an

important decision about their personal

health.

• Ask their reason for choosing not to take the

medication.

• Don’t accept “I just don’t like pills.” Tell them

you’re sure they wouldn’t make such an

important decision without having a reason.

• Offer as examples reasons others might

choose not to take medication. For instance,

they:

1. Don’t believe they ever needed it; never

were mentally ill

2. Don’t believe they need it anymore; cured

3. Don’t like the side effects

4. Fear the medication will harm them

5. Struggle with objections or ridicule of
 

friends and family members
 

6. Feel taking medication means they are not

personally in control

Transition to topics other

than psychiatric medications

Ask what supports or techniques they use to

assist with emotions and behaviors when they

choose not to take the medication.

General Approach

The approach when talking with clients about

psychiatric medication is exactly the same as

when talking about their substance abuse decisions.

• Explore the triggers or cues that led to the

undesired behavior (either taking drugs of

abuse or not taking prescribed psychiatric

medications).

• Review why the undesired behavior seemed

like a good idea at the time.

• Review the actual outcome resulting from

their choice.

• Ask if their choice got them what they were

seeking.

• Strategize with clients what they could do differently in the future.

464 Common Medications for Disorders
Note to Practitioners

Name brand medications have a limited patent.

When the patent expires the medication may be

made as a generic. The generic name of a medication is the actual name of the drug and never 

changes. Do not be surprised to see a generic

drug made by many different manufacturers.

Manufacturers can make many forms of a single drug with only slight variations. Several

drugs have been made in an extended release

form (CR, controlled release; ER or XR,

extended release; and SR, sustained release).

Extended release drugs act over a long period

of time and do not have to be dosed as often.

A new formulation for drugs is a quick, orally

dissolving tablet that can be taken without

water. Two patent drugs that have been formulated as quick dissolving tablets are Remeron

SolTab and Zyprexa Zydis.

Antipsychotics/Neuroleptics

Generic and brand names

Generic Brand

Traditional antipsychotics

chlorpromazine Thorazine,

Largactil

fluphenazine Prolixin+,

Permitil,

Anatensol

haloperidol Haldol

loxapine Loxitane,

Daxolin

mesoridazine Serentil

molindone Moban, Lidone

perphenazine Trilafon,

Etrafon

pimozide Orap

thioridazine	 Mellaril

thiothixene	 Navane

trifluoperazine	 Stelazine

Novel or atypical antipsychotics

aripiprazole	 Abilify

clozapine	 Clozaril+

olanzapine	 Zyprexa,

Zyprexa Zydis

quetiapine	 Seroquel*

risperidone	 Risperdal

risperidone

long­acting injection Risperdal

Consta

ziprasidone	 Geodon

+ Can cause a serious side effect in the blood

system; must have regular blood tests to monitor potential side effects. Approximately 1 to

2 percent of patients who take clozapine

develop a condition called agranulocytosis, in

which their white blood cell count drops

drastically. As a result, the patient is at high

risk for infections due to a compromised

immune system, and this could be fatal.

However, most patients can be treated successfully by stopping clozapine treatment. To

maintain safety, white blood cell count must

be checked each week for 6 months and

every 2 weeks thereafter. The results must be

sent to the patient’s pharmacy before the

patient can pick up the next supply of medication.

* Seroquel is often used for insomnia.

Purpose

Antipsychotics are most typically used for persons who experience psychotic symptoms as a

result of having some form of schizophrenia,

severe depression, or bipolar illness. They may

Common Medications for Disorders 465
be used to treat brief psychotic episodes caused

by drugs of abuse or other conditions.

Psychotic symptoms may include being out of

touch with reality, “hearing voices,” and having false perceptions (e.g., thinking you are a

famous person, thinking someone is out to hurt

you). These medications can be effective in

either minimizing or stopping the appearance

of these symptoms altogether. In some cases,

these medications can shorten the course of the

illness or prevent it from happening again.

The newest antipsychotics—risperdone, olanzapine, quetiapine, ziprasidone, and aripiprazole—are showing positive effects across a

range of disorders. These medications also

seem to have a mood­stabilizing effect and are

used for bipolar disorder, as well as being

added to antidepressants for severe depressions. Some have been shown to be effective at

relieving anxiety in low doses, but this use is

not approved by the Food and Drug

Administration (FDA).

Usual dose, frequency, and

side effects

All drugs have specific doses and frequencies.

The physician will specify the exact amount of

medication and when it should be taken. How

much medicine and how often to take it are

specified on the prescription bottle. Many medications are taken once a day, some at bedtime

to take advantage of the drowsiness side effect

of some antipsychotic medications. Some medications are taken in pill form or liquid form.

Other medications are given by injection once

or twice per month to ensure that the medication is taken reliably. It is important to take

medications on schedule. It is important that

patients talk to their doctor so that they know

about side effects of medications and what they

need to do to monitor their health.

Prolixen, like other medications marked with

+, can very rarely cause serious side effects in

the blood system called blood dyscrasias

(abnormalities or irregularities in the blood

cells). Persons taking any medications marked

with a + may need to have blood tests on a regular basis to check for these blood disorders.

Novel or atypical antipsychotics like Clozaril,

Risperdal, Seroquel, and Zyprexa are different

from traditional antipsychotics. Novel or atypical antipsychotic medications are more powerful with treatment­resistant schizophrenia but

may also be used with severe depression or

other psychiatric illness. Because the atypical

antipsychotics work in a slightly different way

than traditional antipsychotics they are less

likely to produce serious side effects, such as

tardive dyskinesia or neuroleptic malignant

syndrome (NMS). The most common mild side

effects are either sedation or agitation, especially when starting the medications. The most

worrisome side effects are weight gain and elevated blood sugar and lipids. There is also

some evidence that the use of atypical neuroleptics may lead to the development of diabetes mellitus (Sernyak et al. 2002). These

issues can be medically worrisome as well as

lead to medication noncompliance. Since both

the effectiveness and side effect profiles vary

across both medications and patients, matching

the right medication to the right patient is the

key. The older antipsychotics are cheap, and

the newer ones expensive. People taking

Clozaril must have a blood test every two weeks

in order to monitor for a potential side effect,

agranulocytosis, which is a serious blood disorder. In general, the newer antipsychotics, when

taken in proper dosage, have fewer clinical side

effects and a broader treatment response than

traditional antipsychotics.

Tardive dyskinesia

• Involuntary movements of the tongue or

mouth

• Jerky, purposeless movements of legs, arms,

or entire body

• Usually seen with long­term treatment using

traditional antipsychotic medications, sometimes seen with atypical antipsychotic medications

• More often seen in women

• Risk increases with age and length of time on

the medication

466 Common Medications for Disorders
Neuroleptic malignant syndrome 

• Blood pressure up and down

• Dazed and confused

• Difficulty breathing

• Muscle stiffness

• Rapid heart rate

• Sweating and shakiness

• Temperature above normal

Diabetes mellitus

• Associated with atypical neuroleptics

• Excessive thirst

• Headaches

• Frequent urination

• Cuts/blemishes heal slowly

• Fatigue

Other

• Blurred vision

• Changes in sexual functioning

• Constipation

• Diminished enthusiasm

• Dizziness

• Drowsiness

• Dry mouth

• Lowered blood pressure

• Muscle rigidity

• Nasal congestion

• Restlessness

• Sensitivity to bright light

• Slowed heart rate

• Slurred speech

• Upset stomach

• Weight gain

Note: Any side effects that bother a person

need to be reported to the physician and discussed with him or her.

Anticholinergic/antiparkinsonian medications

like Cogentin and Artane may be prescribed in

order to control movement difficulties associated with the use of antipsychotic medications.

Abilify is a new antipsychotic released in

December 2002. The medication acts as both

an enhancer and an inhibitor of dopamine production by “sensing” when there is too little or

too much dopamine in the brain. Useful in the

treatment of schizophrenia and other psychotic

disorders, side effects include headache, anxiety, and insomnia. Risperdal Consta, approved

in November 2003, is an injection of microencapsulated medication that releases into the

body at a constant level. An injection is usually

given every two weeks. Side effects are similar

to those for Risperdal.

Emergency conditions

Contact a physician and/or seek emergency

medical assistance if the person experiences

involuntary muscle movements, painful muscle

spasms, difficulty in urinating, eye pain, skin

rash, or the symptoms noted under neuroleptic

malignant syndrome and tardive dyskinesia.

Cautions

• Doctors and pharmacists should be told

about all medications being taken (including

dosage), including over­the­counter preparations, vitamins, minerals, and herbal supplements (e.g., St. John’s wort, echinacea,

ginko, ginseng, etc.).

• People taking antipsychotic drugs should not

increase their dose unless this has been

checked with their physician and a change is

ordered.

Special considerations for

pregnant women

For women of child­bearing age who may be or

think they may be pregnant, the physician

should discuss the safety of this medication

before starting, continuing, or discontinuing

medication treatment. Substance abuse counselors may have a role in encouraging this discussion by suggesting this to their clients.

Common Medications for Disorders 467
Antimanic Medications

Generic and brand names

Generic Brand

Lithium products

lithium carbonate* Eskalith,

Eskalith CR,

Lithane,

Lithobid,

Lithonate,

Lithotabs

lithium citrate* Cibalith

Anticonvulsant products

Carbamazepine* Tegretol

divalproex sodium* Depakote,

Depakote

Sprinkle,

Depakote ER

gabapentin Neurontin

lamotrigine Lamictal

levetiracetam Keppra+

oxcarbazepine Trileptal

tiagabine hydrochloride Gabitril

topiramate Topamax,

Topamax

Sprinkle

valproate sodium* Depakene,

Depacon

valproic acid* Depakene

Other

olanzapine Zyprexa,

Zyprexa Zydis

(see antipsychotics for side

effects)

quetiapine fumarate Seroquel

risperidone Risperdal

ziprasidone Geodon

*Needs blood level monitoring

+ Keppra is noted for causing mood changes,

primarily depression and anger in some people. This may limit its use as a mood stabilizer.

It is likely that all of the newer atypical

antipsychotics mentioned above will soon be

FDA approved for mania.

Purpose

Antimanic drugs are used to control the mood

swings of bipolar (manic–depressive) illness,

leveling mood swings so that the client operates

in a moderate mood zone. These medications

even out mood swings, which can decrease

some of the suicidal and other self­harm behaviors seen with bipolar disorders. Additionally,

appropriate treatment with antimanic drugs

can reduce a patient’s violent outbursts toward

others or property. Bipolar illness is characterized by cycling mood changes from severe highs

(mania) to severe lows (depression). Cycles of

mood may be predominantly manic or depressive with normal moods between cycles. The

“highs” and “lows” vary in intensity, frequency, and severity. Mania, if left untreated, may

worsen into a psychotic state. The depression

may result in thoughts of suicide. Bipolar

cycles that occur more often than three times a

year are considered “rapid cycling,” a condition often found in those people with higher

rates of substance abuse. Antimanic medications even out the mood swings so that the person operates in a more moderate zone. By leveling mood swings, some of the suicidal and

468 Common Medications for Disorders
other self­harming behaviors seen with bipolar

disorder can be decreased.

Usual Dose Frequency and

Side Effects

All drugs have specific doses and frequencies.

The physician will specify the exact amount of

medication and when it should be taken. How

much medicine and how often to take it are

specified on the prescription bottle. Most medications in this class are given two to four times

per day. Some extended release formulations

may be given every 12 hours. Dosage is determined by the active amount of the drug found

in the person’s blood after taking the medication and by his or her response to the medication. Expect a check of monthly blood levels

until the person is well established at the optimal dose. The most common side effects to the

anticonvulsants are sedation and weight gain.

Some anticonvulsants are generic and relatively

inexpensive, others are quite expensive.

Lithium’s most common side effects are tremor,

acne, and weight gain. The most common side

effects for the atypical antipsychotics are mentioned above in that section.

Potential side effects

• Blurred vision

• Coma*

• Diarrhea*

• Drowsiness

• Fatigue

• Hand tremor*

• Increased thirst and urination*

• Inflammation of the pancreas

• Irregular heart beats

• Kidney damage*

• Liver inflammation (hepatitis)

• Nausea or vomiting

• Problems with the blood (both red and white

blood cells)

• Rash and skin changes

• Seizures

• Under­ or overactive thyroid*

• Weakness

• Weight gain

* Lithium, anticonvulsants, and atypical

antipsychotics only. Effects vary greatly

between patients.

Note: People taking lithium may require more

fluids than they did before taking lithium. Too

much fluid in a person’s diet can “wash” the

lithium out of his or her system. Too little fluid

can allow the lithium to concentrate in the system. Additionally, anything that can decrease

sodium in the body (i.e., decreased table salt

intake, a low­salt diet, excessive sweating during strenuous exercise, diarrhea, vomiting,

etc.) could result in lithium toxicity. People

taking any antimanic drugs should have blood

levels tested regularly to check the concentration level of the drug in their bodies.

Emergency conditions

Lithium overdose is a life­threatening emergency. Signs of lithium toxicity may include nausea, vomiting, diarrhea, drowsiness, mental

dullness, slurred speech, confusion, dizziness,

muscle twitching, irregular heartbeat, and

blurred vision.

Cautions

• Doctors and pharmacists should be told

about all medications being taken (including

dosage), including over­the­counter preparations, vitamins, minerals, and herbal supplements (e.g., St. John’s wort, echinacea,

ginko, ginseng, etc.).

• People taking antimanic drugs should not

increase their dose unless this has been

checked with their physician and a change is 

ordered.

• Take medications as ordered and at the prescribed times.

• Persons taking antimanic drugs are particularly vulnerable to adverse medical conseCommon Medications for Disorders 469
quences if they concurrently use alcohol

and/or illicit drugs.

• Lithium can cause birth defects in the first 3

months of pregnancy.

• Thyroid function must be monitored if a person takes lithium.

• Heavy sweating or use of products that cause

excessive urination (e.g., coffee, tea, some

high caffeine sodas, diuretics) can lower the

level of lithium in the blood.

• Blood tests for drug levels need to be checked

every 1 to 2 months.

• Use of these drugs will lower the effectiveness

of birth control medications.

Special considerations for

pregnant women

Generally, the use of antipsychotic medications

should be avoided in the first trimester unless

the mother poses danger to herself, to others,

or to the unborn child, or if the mother

exhibits profound psychosis (Cohen 1989).

Some, such as valproic acid, are associated

with several disfiguring malformations if taken

during pregnancy. If this type of medication

must be used during pregnancy, the woman

must be told that there is substantial risk of

malformations (Robert et al. 2001). Lithium is

also a suggested teratogen; children who were

exposed before week 12 of gestation should be

apprised of the increased risk of cardiac

abnormalities. For women taking lithium, the

medication should be monitored every 2 weeks

and ultrasound should be performed on the

fetus to exclude goiter (Mortola 1989).

Tapering and discontinuation of antipsychotic

medication 10 days to 2 weeks before delivery

is generally advised, though the protocols vary

by medication (Mortola 1989). For all women

of child­bearing age who may be or think they

may be pregnant, the physician should discuss

the safety of this medication before starting,

continuing, or discontinuing medication treatment. Substance abuse counselors may have a

role in encouraging this discussion between

their clients and the prescribing clinician.

Antidepressant Medications

Generic and brand names

Generic Brand

Monoamine oxidase inhibitors

isocarboxazid Marplan

phenelzine Nardil

tranylcypromine Parnate

Tricyclics and quatracyclics

amitriptyline Elavil

amoxapine Asendin

clomipramine Anafranil

desipramine Nopramin,

Pertofrane

doxepin Sinequan

imipramine Tofranil

maprotiline Ludiomil

nortriptyline Pamelor

protriptyline Vivactil

SSRIs—selective serotonin reuptake inhibitors

citalopram Celexa

escitalopram oxalate Lexapro

fluoxetine Prozac, Prozac

Weekly,

Sarafem

fluvoxamine Luvox

paroxetine Paxil, Paxil CR

sertraline Zoloft

470 Common Medications for Disorders
Others

bupropion	 Wellbutrin,

Wellbutrin SR

mirtazapine	 Remeron,

Remeron

SolTab

nefazodone	 Serzone

trazodone	 Desyrel

venlafaxine	 Effexor,

Effexor ER

Purpose

Antidepressant medications are used for moderate to serious depressions, but they can also

be very helpful for milder depressions such as

dysthymia. Most antidepressants must be taken

for a period of 3 to 4 weeks to begin to reduce

or take away the symptoms of depression but a

full therapeutic effect may not be present for

several months. Treatment for a single episode

of major depression should continued for two

years before discontinuing, and since major

depression is a chronic recurrent illness in

many patients, chronic use of antidepressants

is often indicated. Discontinuing antidepressant

therapy before the depression is completely

resolved may result in the client decompensating and possibly becoming medication resistant.

Untreated depression may result in suicide.

Therefore, treatment for depression must be

taken as seriously as treatment for any other

major life­threatening illness. Antidepressants

are also the first line medications for certain

anxiety disorders such as panic disorder, social

phobia, and obsessive­compulsive disorders.

Types of antidepressants

Older and less commonly used (due to safety

and side effects) antidepressants include the

tricyclic and quatracyclic antidepressants

(named for their chemical structures) and the

monoamine oxidase (MAO) inhibitors. MAO

inhibitors are used for “atypical depressions,”

which produce symptoms like oversleeping,

anxiety or panic attacks, and phobias. MAO

inhibitors may also be used when a person does

not respond to other antidepressants. The most

frequently used class of antidepressants is the

selective serotonin reuptake inhibitors (SSRIs).

They are often prescribed because of their

broad effectiveness, low side effects, and safety.

The SSRIs are thought to affect the serotonin

system to reduce symptoms of depression, and

include fluoxetine, paroxetine, sertraline,

citalopram, and escitalopram. Prozac Weekly

is an extended release formula of Prozac (fluoxetine) that can be dosed once per week.

Sarafem is fluoxetine under another label used

for treatment of premenstrual dysphoric disorder. Other new antidepressants, such as venlafaxine (Effexor) work on both the serotonin

and norepinephrine levels. Bupropion

(Wellbutrin) is an antidepressant unrelated to

other antidepressants; it has more effect on

norepinephrine and dopamine levels than on

serotonin levels in the brain. In addition,

bupropion can be “activating” (as opposed to

sedating) and, although not associated with

weight gain or sexual dysfunction like many

other antidepressant medications, it should be

avoided by people who are at risk for or who

currently have a seizure disorder.

Usual dose and frequency

and side effects

All drugs have specific doses and frequencies.

The physician will specify the exact amount of

medication and when it should be taken. How

much medicine and how often to take it are

specified on the prescription bottle. Several

factors are considered before an antidepressant

is prescribed: the type of drug, the person’s

individual body chemistry, weight, and age.

Clients are generally started on a low dose, and

the dosage is slowly raised until the optimal

effects are reached without the appearance of

troublesome side effects. The most usual side

effects to the older tricyclics are common and

include dry mouth and sedation, but these

drugs are inexpensive. For SSRIs, both mild

sedation and mild agitation are sometimes

found and this class includes both generic modCommon Medications for Disorders 471
erate­expense and brand­only (expensive) versions. The most difficult SSRI side effect is

decreased sexual performance, which may be

difficult for many patients to discuss.

Sleeplessness and agitation are the most common side effects for both bupropion and venlafaxine (both expensive, but bupropion is soon

to be generic with decreased cost).

Potential side effects

MAO inhibitors

• Blood cell problems (both white and red

cells)

• Dizziness when changing position

• Fluid retention

• Headache

• High blood pressure crisis

• Insomnia

• Lack of appetite

• Rapid heart beat

Tricyclics and quatracyclics

• Allergic reactions

• Blood cell problems (both white and red

cells)

• Blurred vision

• Change in sexual desire

• Changes in heartbeat and rhythm

• Constipation

• Decrease in sexual ability

• Difficulty with urination

• Dizziness when changing position

• Dry mouth

• Fatigue

• Heart block

• Increased sweating

• Kidney failure (with Asendin)

• Muscle twitches

• Neuroleptic malignant syndrome (with

Asendin)

• Seizures

• Stroke

• Weakness

• Weight gain

SSRIs

• Anxiety, agitation, or nervousness

• Change in sexual desire

• Confusion

• Decrease in sexual ability

• Diarrhea or loose stools

• Dizziness

• Dry mouth

• Headache

• Heart rhythm changes

• Increased sweating

• Insomnia or sleepiness

• Lack or increase of appetite

• Shakiness

• Stomach upset

• Taste disturbances (with Wellbutrin)

• Weight loss or gain

Emergency conditions

An overdose of any of the MAO inhibitors, tricyclics, quatracyclics, or other antidepressants

is serious and potentially life threatening and

must be reported to a physician immediately.

While the potential for a fatal outcome is much

less with the SSRIs, the possibility that a person has attempted suicide should be dealt with

as an emergency situation that needs immediate

intervention.

Symptoms of tricyclic and quatracyclic overdose may include rapid heartbeat, dilated

pupils, flushed face, agitation, loss of consciousness, seizures, irregular heart rhythm,

heart and breathing stopping, and death.

Cautions

• Doctors and pharmacists should be told

about all medications being taken (including

dosage), including over­the­counter prepara472 Common Medications for Disorders
tions, vitamins, minerals, and herbal supplements (e.g., St. John’s wort, echinacea,

ginko, ginseng, etc.).

• People taking antidepressant drugs should

not increase their dose unless this has been

checked with their physician and a change is 

ordered.

• Withdrawal from SSRIs and other new

antidepressants can cause flu­like symptoms.

Discontinuting antidepressant therapy should

be done gradually under a physician’s care.

• Take medications as ordered and at the prescribed times.

• Persons taking MAO inhibitors must avoid

all foods with high levels of tryptophan or

tyramine (aged cheese, wine, beer, chicken

liver, chocolate, bananas, soy sauce, meat

tenderizers, salami, bologna, and pickled

fish). High levels of caffeine must also be

avoided. If eaten, these foods may react with

the MAO inhibitors to raise blood pressure to

dangerous levels.

• Many drugs interact with the MAO

inhibitors. Largely for this reason they are

rarely used. Do not take any other medications unless they are approved by the treating physician. Even a simple over­thecounter cold medication can cause life­threatening side effects.

• Clients using MAO inhibitor antidepressants

should check all new medications with a

physician or pharmacist before taking them.

• People taking antidepressant drugs are particularly vulnerable to adverse medical consequences if they concurrently use alcohol

and/or street drugs.

• If there is little to no change after 3 to 4

weeks, talk to the doctor about raising the

dose or changing the antidepressant.

• Treatment with antidepressants usually lasts

a minimum 9 to 12 months. Many patients

are on long­term antidepressant therapy to

avoid the frequency and severity of depressive episodes.

Special considerations for

pregnant women

The use of SSRIs, a class of antidepressant

medication, is safer for the mother and fetus

than are tricyclic antidepressants (Garbis and

McElhatton 2001). Fluoxetine (Prozac) is the

most studied SSRI in pregnancy and no

increased incidence in malformations was

noted, nor were there neurodevelopmental

effects observed in preschool­age children

(Garbis and McElhatton 2001). However, possible neonatal withdrawal signs have been

observed. Given that the greatest amount of

data are available for fluoxetine (Prozac), this

is the recommended SSRI for use during pregnancy (Garbis and McElhatton 2001). MAO

inhibitors use is contraindicated in pregnancy,

and its use should be discontinued immediately

if a woman discovers she is pregnant (Mortola

1989). The physician should discuss the safety

of this medication before starting, continuing,

or discontinuing medication treatment with all

women of child­bearing age who may be or

think they may be pregnant. Substance abuse

counselors may have a role in encouraging this

discussion between their clients and the prescribing physician.

Antianxiety Medications

Generic and brand names

Generic Brand

Antidepressants see above

Benzodiazepines

alprazolam Xanax

chlordiazepoxide Librium,

Libritabs,

Librax

clonazepam Klonopin

clorazepate Tranxene

diazepam Valium

Common Medications for Disorders 473
lorazepam Ativan

oxazepam Serax

Beta­blockers

propranolol Inderal

Other

buspirone BuSpar

hydroxyzine embonate Atarax

hydroxyzine pamoate Vistaril

meprobamate Miltown

olanzapine Zyprexa,

Zyprexa Zydis

quetiapine fumarate Seroquel

risperidone Risperdal

Purpose

Antianxiety medications are used to help calm

and relax the anxious person as well as remove

troubling symptoms associated with generalized

anxiety disorder, posttraumatic stress disorder,

panic, phobia, and obsessive­compulsive disorders. The most common antianxiety medications are the antidepressants and the benzodiazepines. The SSRI antidepressants have

become first line medications for the treatment

of panic, social phobia, and (in higher doses)

obsessive­compulsive disorders. Both benzodiazepines and meprobamate (no longer readily

available) are cross tolerant with alcohol, are

abusable, and have a market as street drugs;

thus most addiction medicine physicians only

use them acutely as alcohol withdrawal

medicines, or as sedatives in acutely psychotic

or manic psychiatric patients. If used in outpatients, these patients would need careful monitoring for tolerance and abuse. They both have

a depressant effect on the central nervous system and are relatively fast acting. Miltown,

rarely prescribed anymore, is a non­benzodiazepine but works very much like one to quickly calm anxiety.

Beta­blockers work on the central nervous system to reduce the flight or fight response.

Inderal is occasionally prescribed for performance anxiety and is nonaddictive.

BuSpar works through the serotonin system to

induce calm. BuSpar takes 3 to 4 weeks to get

into the brain to successfully combat anxiety.

Atarax and Vistaril are antihistamines that use

the drowsiness side effect of the antihistamine

group to calm and relax. Vistaril and Atarax

work within an hour of being taken and, like

BuSpar, are not addictive.

Low doses of Risperdal, Seroquel, and Zyprexa

may be used (though this is expensive, off­label

and is not FDA approved) as non­addictive

antianxiety medications, usually in cases in

which several other medications have failed.

Their special formulation works to reduce anxiety and help the person think more clearly,

though the mechanism for this is unclear.

Usual dose, frequency, and

side effects

All drugs have specific doses and frequencies.

The physician will specify the exact amount of

medication and when it should be taken. How

much medicine and how often to take it are

specified on the prescription bottle. Inderal is

taken as needed for performance anxiety or

regularly if it is being used for treatment of a

heart condition. People are usually started on

a low dose of medication, which is raised gradually over time until symptoms are removed or

diminished. Major factors considered in establishing the correct dose are individual body

chemistry, weight, and ability to tolerate the

medication. Clients taking benzodiazepines for

longer than 4 to 8 weeks may develop physical

tolerance to the medication. Benzodiazepines

have a moderate potential for abuse.

Withdrawal symptoms may occur even when

taken as directed, if regular use of benzodiazepines is abruptly stopped. Withdrawal from

high dose abuse of benzodiazepines may be a

life­threatening situation. For these reasons

benzodiazepines are usually prescribed for

brief periods of time—days or weeks—and

474 Common Medications for Disorders
sometimes intermittently for stressful situations

or anxiety attacks. Ongoing continuous use of

benzodiazepines is not recommended for most

people, especially those with a past or current

history of substance abuse or dependence.

Beta­blockers act on the sympathetic nervous

system and are not considered addictive. They

also are used to treat hypertension, thus side

effects might be low blood pressure or dizziness. Beta­blockers may enhance the effects of

other psychotropic medications and are inexpensive.

BuSpar is often used for control of mild anxiety and is considered safe for long­term therapy but is expensive.

Vistaril and Atarax are both antihistamines,

are used as safe nonaddictive medications to

reduce anxiety, and are inexpensive. They may

be used for longer­term therapy. They enhance

the sedative effect of other drugs that cause

drowsiness, and their most common side effects

are dry mouth and sedation, but in older men,

urinary retention may develop and is serious.

Potential side effects

• Blood cell irregularities

• Constipation

• Depression

• Drowsiness or lightheadedness

• Dry mouth

• Fatigue

• Heart collapse

• Irregular heart beat (Miltown)

• Loss of coordination

• Memory impairment (Inderal)

• Mental slowing or confusion

• Slowed heart beat (Valium)

• Stomach upset

• Suppressed breathing

• Weight gain

Potential for abuse or 

dependence

Between 11 and 15 percent of the American

public takes a form of antianxiety medication—

including benzodiazepines—at least once each

year, and if antidepressants are included, this

figure is doubled. Benzodiazepines may cause

at least mild physical dependence in almost

everyone who uses the medication for longer

than 6 months (i.e., if the medicine is abruptly

stopped, the person will experience anxiety,

increased blood pressure, fast heart beat, and

insomnia). However, becoming physically

dependent on benzodiazepines does not mean

abuse or addiction. Fewer than 1 percent of

those without an addiction history who take

benzodiazepines develop a substance abuse

problem. In general, abuse and dependence

occur at lower rates with long­acting antianxiety medications (e.g., Klonopin, Serax, and

Tranxene). Abuse and dependence are more

likely to occur with faster­acting, high­potency

antianxiety medications (e.g., Ativan, Valium,

and Xanax).

Emergency conditions

High doses of Valium can cause slowed heartbeat, suppression of breathing, and heart stoppage.

Withdrawal from regular use of any of the benzodiazepines and similar medications must be

done slowly over a month’s time. Abrupt withdrawal from these drugs can cause hallucinations, delusions and delirium, disorientation,

difficulty breathing, hyperactivity, and grand

mal seizures. To avoid these acute withdrawal

symptoms, a protocol for decreasing or tapering off doses of benzodiazepine is needed.

Overdose on the older tricyclic medications,

which are often used for combined anxiety

depression disorders, can be life threatening

and immediate referral to emergency care is

indicated.

Common Medications for Disorders 475
Cautions

• Doctors and pharmacists should be told

about all medications being taken (including

dosage), including over­the­counter preparations, vitamins, minerals, and herbal supplements (e.g., St. John’s wort, echinacea,

ginko, ginseng, etc.).

• People taking antianxiety drugs should not

increase their dose unless this has been

checked with their physician and a change is 

ordered.

• People should not discontinue use of these

medications without talking to a doctor.

• People taking antianxiety medication are

particularly vulnerable to adverse medical

consequences if they concurrently use alcohol

and/or illicit drugs.

• Using alcohol in combination with benzodiazepines may result in breathing failure and

sudden death.

Special considerations for

pregnant women

For use of the antidepressants in pregnancy, see

above section. The current state of knowledge

suggests that benzodiazepine therapy in general

does not have as much of a teratogenic (producing a deformed baby) risk as do other anticonvulsants as long as they are given over a short

time period. It appears that short­acting benzodiazepines, like those used to treat alcohol withdrawal, can be used in low doses for acute uses

such as detoxification, even in the first trimester

(Robert et al. 2001). Long­acting benzodiazepines should be avoided—their use during

the third trimester or near delivery can result

in a withdrawal syndrome in the baby (Garbis

and McElhatton 2001).

During pregnancy, the protein binding of many

drugs, including methadone and diazepam (a

benzodiazepine), is decreased (e.g., Adams and

Wacher 1968; Dean et al. 1980; Ganrot 1972)

with the greatest decrease noted during the

third trimester (Perucca and Crema 1982). This

decreased binding may be due to the decreased

levels of albumin reported during pregnancy

(Yoshikawa et al. 1984). From a clinical standpoint, it may be that pregnant women could be

at risk for developing greater toxicity and side

effects, yet at the same time an increase in

metabolism of the drug may result (such as

found with methadone). This may result in

reduced therapeutic effect from the drug, since

many women require an increase in their dose

of methadone during the last trimester (Pond et

al. 1985). It should be noted that there is a documented withdrawal syndrome in neonates who

have been prenatally exposed to benzodiazepines (Sutton and Hinderliter 1990) and this

syndrome may be delayed in onset more than

that associated with other drugs. For more

information, see the forthcoming TIP Substance

Abuse Treatment: Addressing the Specific

Needs of Women (CSAT in development b).

For all women of child­bearing age who may be

or think they may be pregnant, the physician

should discuss the safety of this medication

before starting, continuing, or discontinuing

medication treatment. Substance abuse counselors may have a role in encouraging this discussion by suggesting this to their clients.

Stimulant Medications

Generic and brand names

Generic Brand

d­amphetamine Dexedrine

l & d­amphetamine Adderall,

Adderall CII,

Adderall XR

methamphetamine Desoxyn

methylphenidate Ritalin, Ritalin

SR, Concerta,

Metadate ER,

Metadate CD,

Methylin ER,

Focalin

pemoline Cylert

modafinil Provigil

476 Common Medications for Disorders
Non­stimulants for AD/HD

atomoxetine hydrochloride Strattera+

bupropion Wellbutrin++

guanfacine Tenex

+ Strattera is FDA approved

+ + Studies have shown bupropion to be effective, but it is not FDA approved for this use

Purpose

Used to treat attention deficit/hyperactivity disorder (AD/HD), which is typically diagnosed in

childhood but also occurring in adults.

Symptoms consistent with AD/HD include short

attention span, excessive activity (hyperactivity), impulsivity, and emotional development

below the level expected for the client’s age.

The underlying manifestation of AD/HD is that

it severely impacts and interferes with a person’s daily functioning. Other conditions that

may be treated with stimulants are narcolepsy,

obesity, and sometimes depression. While stimulants have been shown to reduce substance

abuse onset in children, for adult populations

with substance abuse problems, most addiction

medicine doctors use antidepressants or atomoxitine. People with AD/HD generally report

that they feel “normal” when taking stimulants.

They cite increased concentration, focus, and

ability to stay on task and behave appropriately when taking the medications.

Non­stimulant medications differ somewhat.

Strattera blocks the reuptake of norepinephrine. It works by leaving more norepinephrine in the brain, which in turn reduces

the symptoms of AD/HD. Tenex and Wellbutrin

are non­stimulants that have been used successfully to treat symptoms of AD/HD. The

advantage of these medications is that they are

non­addictive.

Usual dose, frequency, and

side effects

All drugs have specific doses and frequencies.

The physician will specify the exact amount of

medication and when it should be taken. How

much medicine and how often to take it are

specified on the prescription bottle. With stimulants there may be periods when the medication is not to be taken. The most common side

effects of the stimulants are nervousness, sleeplessness, and loss of appetite. Some are expensive, but others are generic and quite inexpensive.

Potential side effects

Stimulants

• Blood disorders (Ritalin and Cylert)

• Change in heart rhythm

• Delayed growth

• Dilated pupils

• Elevated blood pressure

• Euphoria

• Excitability

• Increased pulse rate

• Insomnia

• Irritability

• Liver damage (Cylert)

• Loss of appetite

• Rash

• Seizures (Ritalin and Cylert)

• Tourette’s syndrome (Cylert)

• Tremor

Non­stimulants for AD/HD

• Strattera side effects include:

– High blood pressure

– Nervousness and the side effects similar to

norepinephrine­sparing antidepressants

• Wellbutrin side effects include increased

chance of seizure activity.

Common Medications for Disorders 477
• Tenex side effects include:

– Constipation

– Dizziness

– Dry mouth

– Low blood pressure

– Sleepiness

Note: People taking these medications need to

be monitored closely for tolerance and dependence. AD/HD patients generally note

increased concentration, focus, and ability to

stay on task and behave appropriately when

taking the medications.

Potential for abuse or 

dependence

Prescription stimulant medications may be misused. Recreational or non­medically indicated

uses have been reported for performance

enhancement and/or weight loss. People with

AD/HD or narcolepsy rarely abuse or become

dependent on stimulant medications.

Emergency conditions

Psychiatric symptoms including paranoid delusions, thought disorder, and hallucinations

have been reported with prolonged use or when

taken at high dosages. Overdose with stimulants is a medical emergency. Seek help immediately.

Cautions

• Doctors and pharmacists should be told

about all medications being taken (including

dosage), including over­the­counter preparations, vitamins, minerals, and herbal supplements (e.g., St. John’s wort, echinacea,

ginko, ginseng, etc.).

• People taking stimulant drugs should not

increase their dose unless this has been

checked with their physician and a change is 

ordered.

• People taking stimulant medications are particularly vulnerable to adverse medical consequences if they concurrently use alcohol

and/or illicit drugs.

• With stimulants, there is the potential for

development of tolerance and dependence on

the medications with accompanying withdrawal. The potential for abuse and misuse is

high, as is true with all schedule II drugs.

Special considerations for

pregnant women

For women of child­bearing age who may be or

think they may be pregnant, the physician

should discuss the safety of this medication

before starting, continuing, or discontinuing

medication treatment. Substance abuse counselors may have a role in encouraging this discussion by suggesting this to their clients.

Narcotic and Opioid

Analgesics

Natural opioids

• Opium, morphine, and codeine products

Pure, semi­ or totally synthetic derivatives, opioids

• Heroin, Percodan, Demerol, Darvon, oxycodone, and others

Generic and brand names

Generic Brand

buprenorphine Buprinex

buprenorphine Subutex,

Suboxone*

butorphanol tartarate Stadol

spray

codeine phosphate Codeine

tablets

codeine sulfate Codeine

tablets

478 Common Medications for Disorders
dihydromorphone hydrochloride Dilaudid­5,

Dilaudid

HP

fentanyl transdermal Duragesic

patches

fentanyl transmucosal Fentanyl,

Oraley

hydromorphone hydrochloride Dilaudid

meperidine hydrochloride Demerol

methadone hydrochloride Methadone

morphine hydrochloride Morphine

morphine sulfate Oramorph,

Roxanol,

Statex

oxycodone hydrochloride Roxicodone,

OxyContin

oxymorphone hydrochloride Numorphan

pentazocine hydrochloride Talwin

propoxyphene hydrochloride Darvon

propoxyphene napsylate Darvon­N

tramadol hydrochloride Ultram

* Combined with naloxone and taken sublingually

The following products use a combination of an

opioid or narcotic along with aspirin, Tylenol,

or other pain reliever to treat mild to moderate

pain.

Anesxia 5/50

Capital with Codeine

Darvocet N 100

Darvocet N 50

E­Lor or Wygesic

Empirin or Phenaphen with Codeine #3

Empirin or Phenaphen with Codeine #4

Endocet, Percocet, or Roxicet

Fioricet with Codeine

Fiorinal with Codeine

Lorcet Plus

Lortab

Percodan

Roxicet

Roxicet oral solution (contains alcohol)

Roxiprin

Talacen

Talwin Compound

Tylenol with Codeine

Tylenol with Codeine syrup (contains alcohol)

Tylox

Vicodin

Vicodin ES

Purpose

Some of these drugs are used to control acute

pain that is moderate to severe. They are normally used only for acute pain—and for a short

time—because they could become addictive. An

exception is using opioids to alleviate the

chronic pain associated with cancer, where

research has shown that abuse or addiction to

these medications rarely occurs. Severe and

chronic pain has long been undertreated in the

United States. This is partly due to concerns

about addiction and partly due to laws that

made certain opioids, like heroin, illegal.

However, people with addictions still feel pain

and, in certain situations, they need pain management just like anyone else. To manage pain,

doctors are beginning to prescribe opioids more

freely—including methadone and buprenorphine, which are recognized as effective pain

medications.

Common Medications for Disorders 479
Methadone is a synthetic opioid used in heroin

detoxification programs and to maintain sobriety from heroin addiction. Many people who

have been addicted to heroin have returned to

a productive life because of methadone maintenance programs. Methadone is also occasionally used to provide relief for specific types of

pain.

Usual dose and frequency

All drugs have specific doses and frequencies.

A doctor will specify the exact amount of medication and when a person should take it. How

much medicine and how often to take it are

always specified on the prescription bottle.

Many medications are taken two or more times

a day. Some medications are taken in pill or

liquid form. Others are taken in liquid form. A

few are taken in a nasal spray or as transdermal patches. Injectable narcotics are not listed

here because they are not often used outside a

hospital setting. There are many nonaddictive

pain medications (medications that pose no risk

for addiction) available for pain management

that can be used after acute pain is reduced.

Potential side effects

• Constipation

• Decreased ability to see clearly

• Decreased ability to think clearly

• Flushing and sweating

• Pupil constriction

• Respiratory depression

• Stomach upset

• Tolerance

Potential for abuse or 

dependence

With opioid medications, there is a potential

for the development of tolerance and dependence as well as the possibility of abuse and

severe withdrawal reactions.

Emergency conditions

• Convulsions and/or cardiac arrest with high

dosages

• Overdose may increase pulse rate, and result

in convulsions followed by coma or death

• Overdose may depress the breathing centers

in the brain leading to lack of ability to

breathe

Cautions

• Doctors and pharmacists should be told

about all medications being taken (including

dosage), including over­the­counter preparations, vitamins, minerals, and herbal supplements (e.g., St. John’s wort, echinacea,

ginko, ginseng, etc.).

• People taking opioid drugs should not

increase their dose unless this has been

checked with their physician and a change is 

ordered.

• Persons taking an opioid medication are particularly vulnerable to adverse medical consequences if they concurrently use alcohol

and/or illicit drugs, because alcohol and illicit

drugs can increase the sedation effects of the

opioids.

• With opioid medications there is a potential

for the development of tolerance and dependence as well as the possibility of abuse and

severe withdrawal reactions.

Special considerations for

pregnant women

For all women of child­bearing age who may be

or think they may be pregnant, the physician

should discuss the safety of this medication

before starting, continuing, or discontinuing

medication treatment. Both pregnant women

and their unborn infants can become tolerant

and physically dependent on opioids and this

dependence as well as possible withdrawal syndromes need to be assessed. Substance abuse

counselors may have a role in encouraging this

discussion by suggesting this to their clients.

480 Common Medications for Disorders
Antiparkinsonian Medications

Generic and brand names

Generic Brand

amantadine hydrochloride Symmetrel,

Symadine

benzotropine maleate Cogentin

diphenhydramine hydrochloride Benadryl

trihexyphenidyl hydrochloride Artane

Purpose

These medications are used to counteract the

side effects of the antipsychotic drugs. They are

called antiparkinsonian because the neurological side effects of the antipsychotic medications

are similar to the symptoms of Parkinson’s disease.

Usual dose and frequency

The amount of the medication and the correct

times to take it are labeled on the prescription

bottle. These medications have very specific

doses, and too much can be harmful. As with

all medications, a doctor must be consulted in

order to safely change the dose in response to

side­effect symptoms of the antiparkinsonian

medications.

Potential side effects

• Constipation

• Dizziness

• Dry mouth

• Heart failure

• Irritability

• Light­headedness

• Stomach upset

• Tiredness

Emergency conditions

Report any overdose, changes in heart rate or

rhythm to the doctor immediately.

Abuse liability of anticholinergic medications

Anticholinergic medications such as benztropine, trihexyophenidyl, and diphenydramine are used as adjuncts to neuroleptics to

control extrapyramidal side effects. However,

despite their utility, these substances can be

abused by some patients with severe mental illness who require neuroleptics. One patient survey found that many abusers of anticholinergics used these agents “to get high, to increase

pleasure, to decrease depression, to increase

energy and to relax” (Buhrich et al. 2000, p.

929). The survey also found that the misuse of

other drugs accompanied the misuse of anticholinergics. Consequently, in the context of

COD, providers and consumers need to be

aware of the abuse potential of anticholinergics. Open communication between providers

and patients is critical to avoid complication

from the abuse of these substances.

Cautions

• Doctors and pharmacists should be told

about all medications being taken (including

dosage), including over­the­counter preparations, vitamins, minerals, and herbal supplements (e.g., St. John’s wort, echinacea,

ginko, ginseng, etc.).

• People taking antiparkinsonian drugs should

not increase their dose unless this has been

checked with their physician and a change is 

ordered.

Special considerations for

pregnant women

The risk of malformation associated with benztropine, trihexylphenidyl, and diphenhydramine is not clear, although there is some

evidence to suggest that amantadine may be

teratogenic (Mortola 1989). For all women of

Common Medications for Disorders 481
child­bearing age who may be or think they

may be pregnant, the physician should discuss

the safety of this medication before starting,

continuing, or discontinuing medication treatment. Substance abuse counselors may have a

role in encouraging this discussion by suggesting this to their clients.

Hypnotics

Generic and brand names

Generic Brand

Barbiturates

secobarbital Seconal

Benzodiazepines

estazolam ProSom

flurazepam Dalmane

temazepam Restoril

triazolam Halcion

Non­benzodiazepine

zaleplon Sonata

zolpidem Ambien

sedating antidepressants trazedone, mirtazepine,

Serzone,

tricyclics

anticonvulsants gabapentin,

divalproex,

topiramate

Purpose

Hypnotics are used to help a person with sleep

disturbances get restful sleep. Lack of sleep is

one of the greatest problems faced by people

with chemical dependency and psychiatric illness. It can cause the symptoms of these disorders to worsen. For example, mood changes,

psychosis, and irritability increase with insomnia. Lack of sleep diminishes a person’s ability

to think clearly or process information. Sleep–

wake cycles and the body’s ability to heal itself

also suffer when a person is sleep deprived.

Older hypnotics cause the body to slow down

and “pass out” or sleep. However, they also

have a tendency to disturb sleep­staging cycles.

Benzodiazepines enhance the body’s natural

calming agents, which induces sleep. Ambien

and Sonata are non­benzodiazepines that affect

one of the body’s receptors for the natural

calming agent, GABA. These medications

induce sleep. They are short acting and do not

disturb sleep­staging cycles. Rebound insomnia

is a side effect of both Ambien and Sonata.

This side effect can be produced if the medications are used for more than 2 weeks and then

abruptly stopped.

Antidepressant sleep enhancers work by using

their sleep producing side effects to induce

sleep. They are nonaddictive but have the

capacity to produce all the side effects of their

class of antidepressant. Atypical antipsychotics

use their calming and sedation side effects to

induce sleep. They are non­addictive but have

the capacity to produce all the side effects of

atypical antipsychotics.

Paradoxically, those with addiction disorders

can become rapidly tolerant and dependent on

the most commonly used hypnotics, which are

the benzodiazepines and zolpidem (barbiturates are now rarely used). Tolerance can lead

to decreasing effectiveness, escalating doses,

and an even worse sleep disorder when the

agent is withdrawn. For this reason, most

addiction medicine doctors use anticonvulsants, sedating antidepressants, or sedating

antihistamines if the sleep problem continues

past acute withdrawal symptoms.

Usual dose and frequency

All drugs have specific doses and frequencies.

The physician will specify the exact amount of

medication and when it should be taken. How

much medicine and how often to take it are

482 Common Medications for Disorders
specified on the prescription bottle. All of these

medications are generally used for limited periods (3 to 4 days for barbiturates or up to a

month for others). For all of these medications,

tolerance develops quickly and eventually the

usual dose will no longer help the person to

sleep.

Potential side effects

• Breathing difficulty (Secobarbital)

• Dizziness

• Drowsiness

• Hangover or daytime sleepiness

• Headache

• Lethargy

• Weakness

Note: There are many drawbacks to long­term

use of hypnotics (sleeping pills) such as damaged sleep staging and addiction. Even Ambien

and Sonata, if taken for longer than 7 to 14

days, can have a discontinuation rebound

insomnia effect. Newer nonaddictive medications are now available to treat insomnia.

Potential for abuse or 

dependence

See Potential for Abuse or Dependence for

benzodiazepines.

Emergency conditions

• Overdose with any of these medications can

be life threatening. Seek help immediately in

the event of an overdose.

• Combinations of alcohol and barbiturates or

alcohol and benzodiazepines can be deadly.

Cautions

• Doctors and pharmacists should be told

about all medications being taken (including

dosage), including over­the­counter preparations, vitamins, minerals, and herbal supplements (e.g., St. John’s wort, echinacea,

ginko, ginseng, etc.).

• People taking hypnotic drugs should not

increase their dose unless this has been

checked with their physician and a change is 

ordered.

• People taking hypnotic medications are particularly vulnerable to adverse medical consequences if they concurrently use alcohol

and/or illicit drugs.

• With hypnotics, there is the potential for

development of tolerance and dependence on

the medications with accompanying withdrawal. The potential for abuse and misuse is

high.

Special considerations for

pregnant women

Barbiturate use during pregnancy has been

studied to some extent, but the risk of medication should be discussed with the patient

(Robert et al. 2001). There also are reports of a

withdrawal syndrome in the neonate (newborn

baby) following prenatal exposure to some barbiturates (Kuhnz et al. 1988). For all women of

child­bearing age who may be or think they

may be pregnant, the physician should discuss

the safety of this medication before starting,

continuing, or discontinuing medication treatment. Substance abuse counselors may have a

role in encouraging this discussion by suggesting this to their clients.

Addiction Treatment

Medications

Generic and brand names

Generic Brand

Antialcoholic

Disulfram Antabuse

Opiate blockers and antialcoholic

Naltrexone hydrochloride ReVia, Depade

Common Medications for Disorders 483
Partial opiate blockers

buprenorphine Suboxone,

Subutex

Opiate maintenance

methadone hydrochloride Methadone

Other

Acamprosate*

* Works through the GABA system and holds

promise for alcohol craving and preventing

relapse through a different method than naltrexone. Not reported to be psychoactive.

Purpose

These drugs are used to reduce cravings and

the psychological reward from initial use of

alcohol or opioids.

Antabuse causes a toxic reaction if alcohol is

drunk; that is, it causes an unpleasant physical

reaction when the person consumes even a

small amount of alcohol. It is used as an aversion therapy for some clients who chronically

abuse alcohol to help them remain in a state of

enforced sobriety which allows time for supportive and psychotherapeutic treatment to be

applied. Antabuse is not psychoactive,

although it may make hallucinations worse at

high doses (i.e., above 500 mg/day). Patients

need to avoid all alcohol, even in other sources

such as cooking or skin care products, because

any alcohol can cause reactions.

Naltrexone completely blocks the pleasurable

reinforcement that comes from opioids. It is

more commonly used to reduce craving for

alcohol and reduce the duration of any relapse

to drinking. In research studies it has been

shown to moderately decrease alcohol craving

and relapse. It is nonpsychoactive, but can

interfere with the use of opioids for acute pain.

Buprenorphine is a prescription medication

approved in 2002 for treating opioid addiction.

It can be used for both opioid withdrawal and

as a substitute for opioids in long­term treatment. Buprenorphine is the first medication

available to doctors for use in their office­based

practice. At low doses, it acts like methadone

and satisfies the dependent person’s need for

an opioid to avoid painful withdrawal. It does

not provide the user with the euphoria or rush

typically associated with use of other opioids or

narcotics. At moderate to high doses, it can

precipitate withdrawal. It is, therefore, safer in

overdose than methadone.

Methadone has been used in the United States

for maintenance treatment of opioid addiction

since the 1960s. It is a synthetic, long­acting

drug used in heroin detoxification programs to

maintain abstinence from heroin addiction.

When used in proper doses, methadone stops

the cravings but does not create euphoria,

sedation, or an analgesic effect. Many people

who have been addicted to heroin have

returned to a productive life because of

methadone maintenance treatment programs.

Methadone also is occasionally used to provide

relief for specific types of pain.

Usual dose and frequency

All drugs have specific doses and frequencies.

The physician will specify the exact amount of

medication and when it should be taken. How

much medicine and how often to take it are

specified on the prescription bottle. Antabuse

should never be given to clients without their

full knowledge or when they are intoxicated. It

should not be given until the client has

abstained from alcohol for at least 12 hours. A

daily, uninterrupted dose of Antabuse is continued until the client is in full and mature

recovery and has reorganized his or her life to

maintain recovery. Maintenance therapy may

be required for months or even years.

Naltrexone is usually taken once a day but can

be taken at a higher dose every second or third

day. It is usually started at full dose. Clients

should continue to take naltrexone until they

484 Common Medications for Disorders
have reached full and mature recovery and

have reorganized their life to maintain recovery.

Suboxone is given as a sublingual tablet (it is

absorbed under the tongue). It is not absorbed

if swallowed or chewed. If injected intravenously, Suboxone will cause opioid withdrawal. Suboxone and Subutex can be given by prescription and do not require daily attendance

at a clinic. This is an advantage for persons

who do not live near a methadone clinic.

Potential Side Effects

Potential side effects for Antabuse:

• Dark urine

• Drowsiness

• Eye pain

• Fatigue

• Impotence

• Indigestion

• Inflammation of optic nerve

• Jaundice

• Light colored stool

• Liver inflammation

• Loss of vision

• Psychotic reactions

• Skin rashes, itching

• Tingling sensation in arms and legs

Potential side effects for the opioid

blockers/opioids are similar to the class of opioid drugs (if buprenorphine is given in high

dose, opioid withdrawal symptoms may occur):

• Abdominal cramps

• Body aches lasting 5–7 days

• Diarrhea

• Dizziness

• Fatigue

• Headache

• Insomnia

• Nausea

• Nervousness

• Opioid withdrawal (in some cases)

• Runny eyes and nose

• Severe anxiety

• Vomiting

Emergency Conditions

• Convulsions and/or cardiac arrest with high

dosages.

• Overdose may increase pulse rate, result in

convulsions followed by coma or death.

• Overdose may depress the breathing centers

in the brain leading to inability to breathe.

Cautions

• Doctors and pharmacists should be told

about all medications being taken, including

over­the­counter preparations.

• Persons taking Antabuse should be warned

to avoid even small amounts of alcohol in

other food products or “disguised forms”

(e.g., vanilla, sauces, vinegars, cold and

cough medicines, aftershave lotions, liniments) as this will cause a reaction.

• Persons taking Antabuse should be warned

that consuming even small amounts of alcohol will produce flushing, throbbing in head

and neck, headache, difficulty breathing,

nausea, vomiting, sweating, thirst, chest

pain, rapid heart rate, blurred vision, dizziness, and confusion.

• Persons taking opioid medications should not

increase their dose unless this has been

checked with their physician and a change is 

ordered.

• People taking opioid medications are particularly vulnerable to adverse medical consequences if they concurrently use alcohol

and/or illicit drugs.

• Persons taking Naltrexone should be warned

that if they are dependent on opioids, taking

Naltrexone will cause opioid withdrawal for

up to 3 days and block the effect of any opioids taken for up to 3 days.

Common Medications for Disorders 485
Special considerations for

pregnant women

While it is not recommended that pregnant

women who are maintained on methadone

undergo detoxification, if these women require

detoxification, the safest time to detoxify them

is during the second trimester. For further

information, consult the forthcoming TIP

Substance Abuse Treatment: Addressing the

Specific Needs of Women (CSAT in development b). In contrast, it is possible to detoxify

women dependent on heroin who are abusing

illicit opioids by using a methadone taper.

Buprenorphine has been examined in pregnancy and appears to lack teratogenic effects but

may be associated with a withdrawal syndrome

in the neonate (Jones and Johnson 2001); however, regardless of the efficacy and safety of

buprenorphine with pregnant women, it has

not yet been approved for use with this population. A National Institutes of Health consensus

panel recommended methadone maintenance as

the standard of care for pregnant women with

opioid dependence.

Pregnant women should be maintained on an

adequate (i.e., therapeutic) methadone dose.

An effective dose prevents the onset of withdrawal for 24 hours, reduces or eliminates

drug craving, and blocks the euphoric effects

of other narcotics. An effective dose usually is

in the range of 50–150mg (Drozdick et al.

2002). Dosage must be individually determined,

and some pregnant women may be able to be

successfully maintained on less than 50mg while

others may require much higher doses than

150mg. The dose often needs to be increased as

a woman progresses through gestation, due to

increases in blood volume and metabolic

changes specific to pregnancy (Drozdick et al.

2002; Finnegan and Wapner 1988).

Generally, dosing of methadone is for a 24­

hour period. However, because of metabolic

changes during pregnancy it might not be possible to adequately manage a pregnant woman

during a 24­hour period on a single dose. Split

dosing, particularly during the third trimester

of pregnancy, may stabilize the woman’s blood

methadone levels and effectively treat withdrawal symptoms and craving.

Breastfeeding is not contraindicated for women

who are on methadone. Very little methadone

comes through breast milk; the American

Academy of Pediatrics (AAP) Committee on

Drugs lists methadone as a “maternal medication usually compatible with breastfeeding”

(AAP 2001, pp. 780–781).

The Federal government mandates that prenatal

care be available for pregnant women on

methadone. It is the responsibility of treatment

providers to arrange this care. More than ever,

there is need for collaboration involving obstetric, pediatric, and substance abuse treatment

caregivers. Comprehensive care for the pregnant

woman who is opioid dependent must include a

combination of methadone maintenance, prenatal care, and substance abuse treatment.

Naloxone should not be given to a pregnant

woman as a last resort for severe opioid overdose. Withdrawal can result in spontaneous

abortion, premature labor, or stillbirth

(Weaver 2003). Propranolol (Inderal), labetalol

(Trandate), and metoprolol (Lopressor) are the

beta blockers of choice for treating hypertension (high blood pressure) during pregnancy

(McElhatton 2001); however the impact of

using them for alcohol detoxification during

pregnancy is unclear.

For all women of child­bearing age who may be

or think they may be pregnant, the physician

should discuss the safety of this medication

before starting, continuing, or discontinuing

medication treatment. Substance abuse counselors may have a role in encouraging this discussion by suggesting this to their clients.

This review is an extensive edit and update of

the 5th edition published in 2004; the original

version was published in 2000 by the MidAmerica Addiction Technology Transfer Center

University of Missouri­Kansas City

5100 Rockhill Road

Kansas City, Missouri 64110

http://www.attcnetwok.org/regcenters/index_midamerica.asp

486 Common Medications for Disorders
Appendix G:
 

Screening and

Assessment Instruments

Addiction Severity Index (ASI)

Purpose: The ASI is most useful as a general intake screening tool. It

effectively assesses a client’s status in several areas, and the composite

score measures how a client’s need for treatment changes over time. 

Clinical utility: The ASI has been used extensively for treatment planning and outcome evaluation. Outcome evaluation packages for individual programs or for treatment systems are available.

Groups with whom this instrument has been used: Designed for

adults of both sexes who are not intoxicated (drugs or alcohol) when

interviewed. Also available in Spanish.

Format: Structured interview

Administration time: 50 minutes to 1 hour

Scoring time: 5 minutes for severity rating 

Computer scoring? Yes

Administrator training and qualifications: A self­training packet is

available as well as onsite training by experienced trainers.

Fee for use: No cost; minimal charges for photocopying and mailing

may apply.

Available from: A. Thomas McLellan, Ph.D. 

Building 7

PVAMC 

University Avenue 

Philadelphia, PA 19104 

Phone: (800) 238­2433

487
Alcohol Use Disorders

Identification Test

(AUDIT)

Purpose: The purpose of the AUDIT is to

identify persons whose alcohol consumption

has become hazardous or harmful to their

health.

Clinical utility: The AUDIT screening procedure is linked to a decision process that

includes brief intervention with heavy

drinkers or referral to specialized treatment

for patients who show evidence of more serious alcohol involvement.

Groups with whom this instrument has been

used: Adults, particularly primary care,

emergency room, surgery, and psychiatric

patients; DWI offenders; criminals in court,

jail, and prison; enlisted men in the armed

forces; and workers in employee assistance

programs and industrial settings.

Format: A 10­item screening questionnaire

with 3 questions on the amount and frequency of drinking, 3 questions on alcohol dependence, and 4 on problems caused by alcohol.

Administration time: 2 minutes

Scoring time: 1 minute

Computer scoring? No

Administrator training and qualifications:

The AUDIT is administered by a health professional or paraprofessional. Training is

required for administration. A detailed user’s

manual and a videotape training module

explain proper administration, procedures,

scoring, interpretation, and clinical management.

Fee for use: No

Available from: Can be downloaded 

from Project Cork 

Web site: 

http://www.projectcork.org

Beck Depression

Inventory–II (BDI–II)

Purpose: Used to screen for the presence and

rate the severity of depression symptoms.

Clinical utility: The BDI–II consists of 21

items to assess the intensity of depression.

The BDI­II can be used to assess the intensity

of a client’s depression, and it can also be

used as a screening device to determine

whether there is any current indication of the

need for a referral for further evaluation.

Each item is a list of four statements arranged

in increasing severity about a particular

symptom of depression. These new items

bring the BDI–II into alignment with

Diagnostic and Statistical Manual for Mental

Disorders, 4th edition (DSM­IV) criteria.

Items on the new scale replace items that

dealt with symptoms of weight loss, changes in

body image, and somatic preoccupation.

Another item on the original BDI that tapped

work difficulty was revised to examine loss of

energy. Also, sleep loss and appetite loss items

were revised to assess both increases and

decreases in sleep and appetite.

Groups with whom this instrument has been

used: All clients age 13 through 80 who can

read and understand the instructions, and

clients who cannot read (requires reading the

statements to them).

Format: Paper­and­pencil self­administered

test. 

Administration time: 5 minutes, either selfadministered or administered verbally by a

trained administrator.

Scoring time: N/A

Computer scoring? No. Any staff member

can perform the simple scoring.

Administrator training and qualifications:

Doctoral­level training or masters­level training with supervision by a doctoral­level clinician are required to interpret test results. 

488 Screening and Assessment Instruments
Fee for use: $66 for manual and package of

25 record forms.

Available from: The Psychological 

Corporation

19500 Bulderve

San Antonio, TX 78259

Phone: (800) 872­1726

CAGE Questionnaire

Purpose: The purpose of the CAGE

Questionnaire is to detect alcoholism.

Clinical utility: The CAGE Questionnaire is a

very useful bedside, clinical desk instrument

and has become the favorite of many family

practice and general internists—also very

popular in nursing.

Groups with whom this instrument has been

used: Adults and adolescents (over 16 years)

Format: Very brief, relatively nonconfrontational questionnaire for detection of alcoholism, usually directed “have you ever” but

may be focused to delineate past or present. 

Administration time: Less than 1 minute 

Scoring time: Instantaneous

Computer scoring? No

Administrator training and qualifications:

No training required for administration; it is

easy to learn, easy to remember, and easy to

replicate. 

Fee for use: No

Available from: May be downloaded from 

the Project Cork Web site:

http://www.projectcork.org

Circumstances,

Motivation, and

Readiness Scales 

(CMR Scales)

Purpose: The instrument is designed to predict retention in treatment and is applicable

to both residential and outpatient treatment

modalities.

Clinical utility: The instrument consists of

four derived scales measuring external pressure to enter treatment, external pressure to

leave treatment, motivation to change, and

readiness for treatment. Items were developed from focus groups of recovering staff

and clients and retain much of the original

language. Clients entering substance abuse

treatment perceive the items as relevant to

their experience. 

Groups with whom this instrument has been

used: Adults

Format: 18 items at approximately a thirdgrade reading level. Responses to the items

consist of a 5­point Likert scale on which the

individual rates each item on a scale from

Strongly Disagree to Strongly Agree. Versions

are also available in Spanish and Norwegian.

Administration time: 5 to 10 minutes 

Scoring time: Can be easily scored by reversing negatively worded items and summing the

item values.

Computer scoring? No

Administrator training and qualifications:

Self­administered; no training required for

administration. 

Screening and Assessment Instruments 489
Fee for use: No

Available from:	 George De Leon, Ph.D., or

Gerald Melnick, Ph.D.

National Development and

Research Institutes, Inc.

71 West 23rd Street

8th Floor

New York, NY 1001

Phone: (212) 845­4400

Fax: (917) 438­0894

E­mail:

gerry.melnick@ndri.org

http://www.ndri.org

Clinical Institute

Withdrawal

Assessment (CIWA-Ar)

Purpose: Converts DSM­III­R items into

scores to track severity of withdrawal; measures severity of alcohol withdrawal.

Clinical utility: Aid to adjustment of care

related to withdrawal severity.

Groups with whom this instrument has been

used: Adults

Format: A 10­item scale for clinical quantification of the severity of the alcohol withdrawal syndrome.

Administration time: 2 minutes 

Scoring time: 4 to 5 minutes

Computer scoring? No

Administrator training and qualifications:

Training is required and the CIWA is administered by nurses, doctors, and research associates/detoxification unit workers.

Fee for use: No

Available from: Dr. E.M. Sellers

Ventana Clinical Research 

Corporation

340 College Street

Suite 400

Toronto, Canada

M5T 3A9

Phone: (416) 963­9338

Fax: (416) 963­9732

Drug Abuse Screening

Test (DAST)

Purpose: The purpose of the DAST is (1) to

provide a brief, simple, practical, but valid

method for identifying individuals who are

abusing psychoactive drugs; and (2) to yield a

quantitative index score of the degree of

problems related to drug use and misuse. 

Clinical utility: Screening and case finding;

level of treatment and treatment/goal planning.

Groups with whom this instrument has been

used: Individuals with at least a sixth­grade

reading level.

Format: A 20­item instrument that may be

given in either a self­report or a structured

interview format; a “yes” or “no” response is

requested from each of 20 questions. 

Administration time: 5 minutes 

Scoring time: N/A

Computer scoring? No. The DAST is

planned to yield only one total or summary

score ranging from 0 to 20, which is computed

by summing all items that are endorsed in the

direction of increased drug problems. 

Administrator training and qualifications:

For a qualified drug counselor, only a careful

reading and adherence to the instructions in

the “DAST Guidelines for Administration and

Scoring,” which is provided, is required. No

other training is required.

490 Screening and Assessment Instruments
Fee for use: The DAST form and scoring key

are available either without cost or at nominal cost.

Available from: Centre for Addiction and 

Mental Health

Marketing and Sales

Services

33 Russell Street

Toronto, Ontario, Canada

M5S 2Sl 

Phone: (800) 661­1111

(Continental North

America)

International and Toronto

area: (416) 595­6059

Global Appraisal of

Individual Needs

(GAIN)

Purpose: The GAIN was developed to implement an integrated biopsychosocial model of

treatment assessment, planning, and outcome

monitoring that can be used for evaluation,

clinical practice, and administrative purposes.

Clinical utility: The GAIN embeds questions

for documenting substance use disorder,

attention deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder,

and pathological gambling; dimensional

patient placement criteria for

intoxication/withdrawal, health distress, mental distress, and environment distress to guide

movement among and between levels of care;

treatment planning; reporting requirements

related to the State client data system; and

measures of a core set of clinical status and

service utilization outcomes used in the Drug

Outcome Monitoring Study.

Groups with whom this instrument has been

used: Adults and adolescents

Format: The content of the GAIN is divided

into eight areas: background and treatment

arrangements, substance use, physical health,

risk behaviors, mental health, environment,

legal, and vocational. In each area, the questions check for major problem areas and the

recency of any problems. 

Administration time: 15 to 30 minutes

Scoring time: 20 minutes

Computer scoring? No

Administrator training and qualifications:

N/A

Fee for use: The GAIN and its products are

tools that are proprietary products owned by

Chestnut Health Systems either exclusively or

jointly and protected under U.S. copyright

laws. The current work is in beta test form,

but can be used for evaluation and research

under a non­exclusive, non­transferable, limited license at the cost of $1 plus any materials/assistance requested.

Available from: The Lighthouse Institute

Chestnut Health Systems

720 West Chestnut

Bloomington, IL 61701

Phone: (309) 827­6026

http://www.chestnut.org/li/gain/

Level of Care

Utilization System

(LOCUS)

Purpose: To assess immediate service needs

(e.g., for clients in crisis); to plan resource

needs over time, as in assessing service

requirements for defined populations; to

monitor changes in status or placement at different points in time. 

Clinical utility: LOCUS is divided into three

sections. The first section defines six evaluation parameters or dimensions: (1) risk of

harm; (2) functional status; (3) medical,

addictive, and psychiatric co­morbidity; (4)

recovery environment; (5) treatment and

recovery history; and (6) engagement. A fivepoint scale is constructed for each dimension

and the criteria for assigning a given rating or

Screening and Assessment Instruments 491
score in that dimension are elaborated. In

dimension IV, two subscales are defined,

while all other dimensions contain only one

scale.

Groups with whom this instrument has been

used: Adults

Format: A document that is divided into

three sections. 

Administration time: 15 to 30 minutes

Scoring time: 20 minutes

Computer scoring? No

Administrator training and qualifications: Groups with whom this instrument has been

used: Adults N/A

Fee for use: No

Available from: American Association of 

Community Psychiatrists

Michigan Alcoholism

Screening Test (MAST)

Purpose: Used to screen for alcoholism with

a variety of populations.

Clinical utility: A 25­item questionnaire

designed to provide a rapid and effective

screen for lifetime alcohol­related problems

and alcoholism.

Groups with whom this instrument has been

used: Adults

Format: Consists of 25 questions 

Administration time: 10 minutes

Scoring time: 5 minutes

Computer scoring? No

Administrator training and qualifications:

No training required.
 

Fee for use: Fee for a copy but no fee for use.
 

Available from: Melvin L. Selzer, M.D.

6967 Paseo Laredo

La Jolla, CA 92037­6425

M.I.N.I. Plus

Purpose: Assists in the assessment and tracking of patients with greater efficiency and

accuracy.

Clinical utility: The M.I.N.I. is not designed

or intended to be used in place of a full medical and psychiatric evaluation by a qualified

licensed physician­psychiatrist. It is intended

only as a tool to facilitate accurate data collection and processing of symptoms elicited by

trained personnel.

Format: An abbreviated psychiatric structured interview that takes approximately 15

to 20 minutes to administer. It uses decision

tree logic to assess the major adult Axis I disorders in DSM­IV and ICD­10. It elicits all

the symptoms listed in the symptom criteria

for DSM­IV and ICD­10 for 15 major Axis I

diagnostic categories, one Axis II disorder,

and for suicidality. Its diagnostic algorithms

are consistent with DSM­IV and ICD­10 diagnostic algorithms.

Administration time: 15 to 20 minutes

Scoring time: N/A

Computer scoring? A computerized version

of the M.I.N.I. is available in six languages in

the MINI Outcomes program.

Administrator training and qualifications:

The M.I.N.I. was designed to be used by

trained interviewers who do not have training

in psychiatry or psychology. 

Fee for use: The M.I.N.I. is made available

at no charge on the Internet, mainly for

researchers and clinicians who may make single copies of the M.I.N.I. for their own use.

When the M.I.N.I. is used in a research study

or published paper, appropriate credit should

492 Screening and Assessment Instruments
be given for its use. The proper citation is

provided on the last page of the M.I.N.I.

Available from: Medical Outcome Systems,

Inc.

Psychiatric Research

Interview for

Substance and Mental

Disorders (PRISM)

Purpose: The instrument was designed to

maximize reliability and validity in community samples, alcohol, drug, and co­occurring

disorder treatment samples. 

Clinical utility: Although primarily designed

as a research instrument, the PRISM provides systematic coverage of alcohol­ and

drug­related experiences and symptoms that

may be useful in identifying areas of focus for

treatment. Additionally, the unusually high

reliability of the depression diagnoses in individuals with heavy drinking may provide a

better basis for treatment decisions than less

consistent methods for assessing major

depression and dysthymia.

Groups with whom this instrument has been

used: Adults

Format: The PRISM is a semistructured clinician­administered interview that measures

DSM­III, DSM­III­R, and DSM­IV diagnoses

(current and past) of alcohol, drug, and psychiatric disorders and continuous measures of

severity, organic, etiology, treatment, and

functional impairment. 

Administration time: 1 to 3 hours

Scoring time: Immediately

Computer scoring? Yes

Administrator training and qualifications:

Interviewer should have at least a master’s

degree in a clinical field and some clinical

experience. Training is required for administration. Training for the administrator

involves a self­study manual, ratings of videotapes of interviews, and small group sessions

with an experienced trainer. 

Fee for use: No

Available from: Dr. Deborah Hasin 

New York State

Psychiatric Institute 

Box 123 722 

West 168th Street

New York, NY 10032 

Phone: (212) 960­5518 

Cost/source of computerized scoring: Call Dr. 

Hasin for current 

information.

Readiness to Change

Questionnaire

Purpose: Designed to assist the clinician in

determining the stage of readiness for change

among problem drinkers or people with alcohol use disorders.

Clinical utility: Assesses drinker’s readiness

to change drinking behaviors; may be useful

in assignment to different types of treatment.

Groups with whom this instrument has been

used: Adults and adolescents

Format: A brief 12­item questionnaire consisting of three subscales.

Administration time: 2 to 3 minutes

Scoring time: 1 to 2 minutes

Computer scoring? No

Administrator training and qualifications:

No training is required.

Fee for use: No

Screening and Assessment Instruments 493
Available from: Center for Alcohol and 

Drug Studies

Plummer Court, Carliol

Place

Newcastle upon Tyne

NE1 6UR

UNITED KINGDOM

Phone: 44(0)191219 5648

Fax: 44(0)191219 5649

Recovery Attitude and

Treatment Evaluator

(RAATE)

Purpose: Designed to assist in placing

patients into the appropriate level of care at

admission, in making continued stay or transfer decisions during treatment (utilization

review), and documenting appropriateness of

discharge.

Clinical utility: The RAATE provides objective documentation to assist in making appropriate treatment placement decisions; it

strengthens individualized care and facilitates

more individualized treatment planning; it

measures treatment process; and it assesses

the need for continuing care and discharge

readiness.

Groups with whom this instrument has been

used: Adults

Format: A 35­item structured interview

Administration time: 20 to 30 minutes

Scoring time: Less than 5 minutes

Computer scoring? No

Administrator training and qualifications:

Training is required for administration. The

RAATE is administered by trained chemical

dependency professional (RAATE­CE) or

patient (RAATE­QI).

Fee for use: Yes. The RAATE manual is

available for $35.00 and the scoring templates

are $8.75.

Available from: Evince Clinical 

Assessments

P.O. Box 17305

Smithfield, RI 02917

Phone: (401) 231­2993

Toll­free in USA:

(800)­755­6299

http://www.evinceassessment.com

Structured Clinical

Interview for DSM-IV

Disorders (SCID-IV)

Purpose: Obtains Axis I and II diagnoses

using the DSM­IV diagnostic criteria for

enabling the interviewer to either rule out or

establish a diagnosis of “drug abuse” or

“drug dependence” and/or “alcohol abuse” or

“alcohol dependence.”

Clinical utility: A psychiatric interview.

Groups with whom this instrument has been

used: Psychiatric, medical, or communitybased normal adults.

Format: A psychiatric interview form in

which diagnosis can be made by the examiner

asking a series of approximately 10 questions

of a client.

Administration time: Administration of Axis

I and Axis II batteries may require more than

2 hours each for patients with multiple diagnoses. The Psychoactive Substance Use

Disorders module may be administered by

itself in 30 to 60 minutes.

Scoring time: Approximately 10 minutes

Computer scoring? No. Diagnosis can be

made by the examiner asking a series of questions of a client. 

Administrator training and qualifications:

Designed for use by a trained clinical evaluator at the master’s or doctoral level, although

in research settings it has been used by bachelor’s­level technicians with extensive training.

494 Screening and Assessment Instruments
Fee for use: Yes

Available from: American Psychiatric 

Publishing, Inc.

1400 K Street, N.W.

Washington, DC 20005

Substance Abuse

Treatment Scale (SATS)

Purpose: To assess and monitor the progress

that people with severe mental illness make

toward recovery from substance use disorder.

Clinical utility: This scale is for assessing a

person’s stage of substance abuse treatment,

not for determining diagnosis.

Groups with whom this instrument has been

used: Adults, adolescents (over 16 years)

Format: Very brief, relatively nonconfrontational questionnaire for detection of alcoholism, usually directed by saying “have you

ever” but may be focused to delineate past or

present. 

Administration time: Less than 1 minute 

Scoring time: Instantaneous

Computer scoring? No

Administrator training and qualifications:

No training required for administration; it is

easy to learn, easy to remember, and easy to

replicate. 

Fee for use: No

Available from: Can be downloaded from the

Center for Mental Health Services Web site, 

University of Rhode

Island Change

Assessment (URICA)

Purpose: The URICA operationally defines

four theoretical stages of change—precontemplation, contemplation, action, and maintenance—each assessed by eight items. 

Clinical utility: Assessment of stages of

change/readiness construct can be used as a

predictor, treatment matching, and outcome

variables. 

Groups with whom this instrument has been

used: Both inpatient and outpatient adults

Format: The URICA is a 32­item inventory

designed to assess an individual’s stage of

change located along a theorized continuum

of change.

Administration time: 5 to 10 minutes to complete 

Scoring time: 4 to 5 minutes

Computer scoring? Yes, computer­scannable

forms.

Administrator training and qualifications:

N/A

Fee for use: No; instrument is in the public

domain. Available from author.

Available from: Carlo C. DiClemente

University of Maryland

Psychology Department

1000 Hilltop Circle

Baltimore, MD 21250

Phone: (410) 455­2415

Screening and Assessment Instruments 495
Appendix H:
 

Screening Instruments
 

This appendix reproduces two screening instruments available for unrestricted use:

• Mental Health Screening Form­III (MHSF­III)

• Simple Screening Instrument for Substance Abuse (SSI­SA)

One of the difficult decisions facing the consensus panel related to the

inclusion of specific screening and assessment instruments. The consensus panel decided to include an instrument for the substance abuse field

to screen for mental health issues and an instrument for mental health

settings to use to screen for substance abuse issues.

Recognizing time, cost, and effort as severe initial barriers to implementing anything new into a treatment service system, the consensus panel

selected two screening instruments that can be reproduced for free and

have instructions that can also be reproduced for free. Information

about other screening instruments and assessment tools is given in

appendix G.

There is clear face validity as well as supportive psychometric findings to

the two screening instruments in this appendix. Neither the questions

nor the formats of the MHSF­III and the SSI­SA are likely to cause difficulty for staff or clients. These two screening techniques require minimal

staff training for their use, and their simplicity makes their incorporation into treatment services relatively easy. Both instruments were

specifically designed for use within a clinical setting for clients receiving

or seeking treatment and for administration and use under the standard

conditions found in most substance abuse and/or mental health clinics.

The consensus panel cautions against other uses of these instruments,

unless the professionals deciding on such use have given full consideration to the limitations of these two specialized screens.

497
The Mental Health

Screening Form-III

With the permission of Project Return

Foundation, Inc., the consensus panel has

taken the opportunity to present the Mental

Health Screening Form­III in its entirety (see

also http://www.projectreturn.org).

Guidelines for Using the

Mental Health Screening

Form-III

The Mental Health Screening Form­III was initially designed as a rough screening device for

clients seeking admission to substance abuse

treatment programs.

Each MHSF­III question is answered either

“yes” or “no.” All questions reflect the respondent’s entire life history; therefore all questions

begin with the phrase “Have you ever...”

The preferred mode of administration is for

staff members to read each item to respondents

and get their “yes” and “no” responses. Then,

after completing all 18 questions (question 6

has two parts), the staff member should inquire

about any “yes” response by asking “When did

this problem first develop?”; “How long did it

last?”; “Did the problem develop before, during, or after you started using substances?”;

and, “What was happening in your life at that

time?” This information can be written below

each item in the space provided. There is additional space for staff member comments at the

bottom of the form.

The MHSF­III can also be given directly to

clients to complete, providing they have sufficient reading skills. If there is any doubt about

someone’s reading ability, have the client read

the MHSF­III instructions and question number one to the staff member monitoring this

process. If the client cannot read and/or comprehend the questions, the questions must be

read and/or explained to him or her.

Whether the MHSF­III is read to a client or he

reads the questions and responds on his own,

the completed MHSF­III should be carefully

reviewed by a staff member to determine how

best to use the information. It is strongly recommended that a qualified mental health specialist be consulted about any “yes” response to

questions 3 through 17. The mental health specialist will determine if a follow­up, face­to­face

interview is needed for a diagnosis and/or treatment recommendation.

The MHSF­III features a “Total Score” line to

reflect the total number of “yes” responses.

The maximum score on the MHSF­III is 18

(question 6 has two parts). This feature will

permit programs to do research and program

evaluation on the mental health­chemical

dependence interface for their clients.1

The first four questions on the MHSF­III are

not unique to any particular diagnosis; however, questions 5 through 17 reflect symptoms

associated with the following diagnoses/diagnostic categories: Q5, Schizophrenia; Q6,

Depressive Disorders; Q7, Posttraumatic Stress

Disorder; Q8, Phobias; Q9, Intermittent

Explosive Disorder; Q10, Delusional Disorder;

Q11, Sexual and Gender Identity Disorders;

Q12, Eating Disorders (Anorexia, Bulimia);

Q13, Manic Episode; Q14, Panic Disorder;

Q15, Obsessive­Compulsive Disorder; Q16,

Pathological Gambling; and Q17, Learning

Disorder and Mental Retardation.

1

Note: The “Total Score” cannot be used with any individual client. Summing the number of “yes” responses cannot be

taken to be indicative of more or less of any “trait” or “dimension.” Even the use of a “Total Score” for research and

program evaluation purposes requires careful understanding of and attention to the fact that fundamentally each item is

an independent and separate screening device/question on its own. That is, every “yes” item is a positive screen suggesting the need for further evaluation, and most items are screens for a particular mental disorder. Anyone using “Total

Scores” for an appropriate narrow set of possibilities related to program evaluation and/or research should take care

that such use does not create confusion.

498 Screening Instruments
The relationship between the diagnoses/diagnostic categories and the above­cited questions

was investigated by having four mental health

specialists independently select the one MHSFIII question that best matched a list of diagnoses/diagnostic categories. All of the mental

health specialists matched the questions and

diagnoses/diagnostic categories in the same

manner, that is, as noted in the preceding paragraph.

A “yes” response to any of questions 5 through

17 does not, by itself, ensure that a mental

health problem exists at this time. A “yes”

response raises only the possibility of a current

problem, which is why a consult with a mental

health specialist is strongly recommended.

Simple Screening

Instrument for

Substance Abuse

The Simple Screening Instrument for

Substance Abuse (SSI­SA) was developed by

the consensus panel of TIP 11, Simple

Screening Instruments for Outreach for

Alcohol and Other Drug Abuse and Infectious

Diseases (Center for Substance Abuse

Treatment 1994c). The SSI­SA has previously

been called the Simple Screening Instrument

for Outreach for Alcohol and Other Drug

Abuse; the Simple Screening Instrument (SSI);

and the Simple Screening Instrument for AOD

(SSI­AOD). To avoid confusion, the consensus

panel suggests using “SSI­SA” (Simple

Screening Instrument for Substance Abuse)

when referring to this screening instrument.

As a government­supported document, the SSISA is in the public domain, can be used without

charge or permission and can be reproduced

without limit, including the instructions. It is a

16­item scale, although only 14 items are scored

so that scores can range from 0 to 14. These 14

items were selected by the TIP 11 consensus

panelists from existing alcohol and drug abuse

screening tools. A score of 4 or greater has

become the established cut­off point for warranting a referral for a full assessment.

Since its publication in 1994 the SSI­SA has

been widely used and its reliability and validity

investigated. Peters and colleagues (2004)

reported on a national survey of correctional

treatment for COD. Reviewing 20 COD treatment programs in correctional settings from 13

States, the SSI­SA was identified as among the

most common screening instruments used.

Peters et al. (2000) found the SSI­SA to be

effective in identifying substance­dependent

inmates, and the SSI­SA demonstrated high

sensitivity (92.6 percent for alcohol or drug

dependence disorder, 87.0 percent for alcohol

or drug abuse or dependence disorder) and

excellent test­retest reliability (.97). Knight et

al. (2000) also found the SSI­SA a reliable substance abuse screening instrument among adolescent medical patients.

Peters and Peyton (1998) evaluated a number

of screening instruments for use by drug

courts and found the Alcohol Dependence

Scale/Addiction Severity Index – Drug Use

section combined, the Texas Christian

University Drug Dependence Screen

(TCUDS), and the SSI­SA “to hold considerable promise for use with participants in drug

court programs” (p. 17).

The Urban Institute (Moore and Mears 2003)

interviewed practitioners within correctionbased drug treatment programs in 13 States

selected to include a diversity of regions and

sizes. Again, the TCUDS and the SSI­SA were

widely used, as was the Michigan Alcohol

Screening Test (MAST). The TCUDS was

deemed to produce fewer false positives than

the SSI­SA. Winters (1995), in a small study of

95 clients from a drug evaluation program,

found a sensitivity of 97.0 percent and specificity of 55.2 percent. “Overall classification

accuracy or ‘hit rate’ was 84.2 percent ....

[Thus] false classifications occurred in 15.8

percent of the sample, yet the majority of the

errors are of the ‘false positive’ type ... which

is the preferred type of error for a screening

test” (p. 3). For program administrators or

clinicians considering the SSI­SA for their own

screening purposes, the false–positive rate will

produce more referrals than other screening

Screening Instruments 499
Mental Health Screening Form­III

Instructions: In this program, we help people with all their problems, not just their addictions. This commitment includes helping people with emotional problems. Our staff is ready to help you to deal with any

emotional problems you may have, but we can do this only if we are aware of the problems. Any

information you provide to us on this form will be kept in strict confidence. It will not be released to any

outside person or agency without your permission. If you do not know how to answer these questions, ask

the staff member giving you this form for guidance. Please note, each item refers to your entire life

history, not just your current situation, this is why each question begins - “Have you ever ....”

1. Have you ever talked to a psychiatrist, psychologist, therapist, social worker, or counselor about an

emotional problem?

YES NO

2. Have you ever felt you needed help with your emotional problems, or have you had people tell you that

you should get help for your emotional problems?

YES NO

3. Have you ever been advised to take medication for anxiety, depression, hearing voices, or for any other

emotional problem?

YES NO

4. Have you ever been seen in a psychiatric emergency room or been hospitalized for psychiatric reasons?

YES NO

5. Have you ever heard voices no one else could hear or seen objects or things which others could not see?

YES NO

6. (a) Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had

trouble concentrating and making decisions, or thought about killing yourself?

YES NO

(b) Did you ever attempt to kill yourself?

YES NO

7. Have you ever had nightmares or flashbacks as a result of being involved in some traumatic/terrible

event? For example, warfare, gang fights, fire, domestic violence, rape, incest, car accident, being shot

or stabbed?

YES NO

8. Have you ever experienced any strong fears? For example, of heights, insects, animals, dirt, attending

social events, being in a crowd, being alone, being in places where it may be hard to escape or get help?

YES NO

9. Have you ever given in to an aggressive urge or impulse, on more than one occasion, that resulted in

serious harm to others or led to the destruction of property?

YES NO

10. Have you ever felt that people had something against you, without them necessarily saying so, or that

someone or some group may be trying to influence your thoughts or behavior?

YES NO

500 Screening Instruments
Mental Health Screening Form­III (continued)

Source: J.F.X. Carroll, Ph.D., and John J. McGinley, Ph.D.; Project Return Foundation, Inc., 2000.

This material may be reproduced or copied, in entirety, without permission.

11. Have you ever experienced any emotional problems associated with your sexual interests, your sexual

activities, or your choice of sexual partner?

YES NO

12. Was there ever a period in your life when you spent a lot of time thinking and worrying about gaining

weight, becoming fat, or controlling your eating? For example, by repeatedly dieting or fasting, engaging

in much exercise to compensate for binge eating, taking enemas, or forcing yourself to throw up?

YES NO

13. Have you ever had a period of time when you were so full of energy and your ideas came very rapidly,

when you talked nearly non­stop, when you moved quickly from one activity to another, when you needed little sleep, and believed you could do almost anything?

YES NO

14. Have you ever had spells or attacks when you suddenly felt anxious, frightened, uneasy to the extent

that you began sweating, your heart began to beat rapidly, you were shaking or trembling, your stomach

was upset, you felt dizzy or unsteady, as if you would faint?

YES NO

15. Have you ever had a persistent, lasting thought or impulse to do something over and over that caused

you considerable distress and interfered with normal routines, work, or your social relations? Examples

would include repeatedly counting things, checking and rechecking on things you had done, washing and

rewashing your hands, praying, or maintaining a very rigid schedule of daily activities from which you

could not deviate.

YES NO

16. Have you ever lost considerable sums of money through gambling or had problems at work, in school,

with your family and friends as a result of your gambling?

YES NO

17. Have you ever been told by teachers, guidance counselors, or others that you have a special learning

problem?

YES NO

Print client’s name: __________________ Program to which client will be assigned: ________________

Name of admissions counselor: ______________________________ Date: ________________________

Reviewer’s comments:______________________________________________________________________

Total Score: ____________(each yes = 1 point)

Screening Instruments 501
instruments, such as the TCUDS, might produce. On the other hand, the SSI­SA is likely

to correctly identify a high percentage of cooperative clients and to miss (false negatives) only

a few—that is, only a few people who warrant a

full evaluation and are likely to have a substance use disorder will be deemed by this

screening instrument not to warrant a full

assessment. Choosing a screening instrument

and designing a screening and assessment treatment process are complex challenges that typically require expert input.

Lastly, the National Health Care for the

Homeless Council recently developed general

recommendations for the care of homeless

patients (Bonin et al. 2004). Within these

guidelines are recommendations to consider the

SSI­SA to screen for substance use problems

(and the MHSF­III to screen for mental disorders).

The following sections are reprinted from TIP

11.

Development of the SSI-SA

Routine screening for substance abuse can be

used to initiate the process of assessment by

identifying a client’s possible problems and

determining whether he or she needs a comprehensive assessment. Ideally, a screening instrument for substance abuse should have a high

degree of sensitivity: It should be broad in its

detection of individuals who have a potential

substance abuse problem, regardless of the specific drug or drugs being abused.

The substance abuse screening instrument presented in this section was designed to encompass a broad spectrum of signs and symptoms

for substance use disorders. These conditions

are characterized by substance use that leads

to negative physical, social, and/or emotional

consequences and loss of control over one’s

pattern and amount of consumption of the substance(s) of abuse.

The view of substance abuse problems and disorders presented in this section and reflected in

the screening instrument is consistent with that

adopted by the World Health Organization and

the American Psychiatric Association. Briefly

stated, this view holds that substance abuse disorders are biopsychosocial disorders, causing

impairment and dysfunction in physical, emotional, and social domains. Certain cognitive

and behavioral signs and symptoms are also

associated with substance abuse (see the observation checklist at the end of the screening

instrument for substance abuse). Although many

of these latter signs and symptoms can be the

result of various medical, psychiatric, and social

problems, individuals with a substance abuse

disorder generally exhibit several of them.

The screening instrument for substance abuse

was developed by first identifying five primary

content domains, which are described in the

sections that follow. The screening questions

then devised were assigned to one or more of

these categories. These screening questions

were adapted from existing tools found in the

published literature. Because most of these

existing tools were designed to screen for alcohol abuse, many items needed to be revised to

address other drugs. The sources for the

screening items included in the instrument are

shown in Figure H­1.

Domains Measured by the

Instrument

Substance consumption

A person’s consumption pattern—the frequency, length, and amount of use—of substances is

an important marker for evaluating whether he

or she has a substance abuse problem.

Questions 1, 10, and 11 in the substance abuse

screening instrument were formulated in order

to help delineate an individual’s consumption

pattern.

Patterns of substance consumption can vary

widely among individuals or even for the same

individual. Although substance use disorders

often consist of frequent, long­term use of substances, addiction problems may also be characterized by periodic binges over shorter periods.

502 Screening Instruments
Figure H­1

Sources for Items Included in the

Simple Screening Instrument for

Substance Abuse

Question No. Source Instrument 

1 Revised Health Screening Survey

(RHSS)

2 Michigan Alcohol Screening Test

(MAST)

3 CAGE

4 MAST, CAGE

5 History of Trauma Scale, MAST,

CAGE

6 MAST, Drug Abuse Screening

Test (DAST)

7 MAST, Problem­Oriented

Screening Instrument for

Teenagers (POSIT)

8 MAST, DAST

9 MAST, DSM­II­R

10 POSIT, DSM­III­R

11 POSIT

12 POSIT

13 MAST, POSIT, CAGE, RHSS,

Alcohol Use Disorders

Identification Test

(AUDIT), Addiction Severity

Index (ASI)

Note: References for these sources appear at the

end of this section.

Preoccupation and loss of

control

The symptoms of preoccupation and loss of

control are common in people with substance

use disorders. Preoccupation refers to an individual spending inordinate amounts of time

concerned with matters pertaining to substance

use. Loss of control is a symptom usually typified by loss of control over one’s use of substances or over one’s behavior while using substances. These symptoms are measured by

screening test questions 2, 3, 9, 11, and 12.

The symptom of preoccupation is marked by

an individual’s tendency to spend a considerable amount of time thinking about, consuming, and recovering from the effects of the substance(s) of abuse. In some cases, the individual’s behavior may be noticeably altered by his

or her preoccupation with these matters. Such

an individual may, for example, lose interest in

personal relationships or may become less productive at work as a result of constant preoccupation with obtaining more of the substance of

abuse.

Loss of control over substance use is typified by

the consumption of more of the substance(s) of

abuse than originally intended. Many persons

with a substance abuse problem feel that they

have no direct, conscious control over how

much and how often they use substances. Such

an individual may, for example, initially intend

to have only one drink but then be unable to

keep from drinking more. He or she may find it

difficult or impossible to stop drinking once he

or she has started. In other instances, a person

who originally plans to use a drug for a short

period of time may find that he or she is

increasingly using it over longer periods than

originally intended.

Loss of behavioral control, on the other hand,

is typified by loss of inhibitions and by behaviors that are often destructive to oneself or others. In many cases, these behaviors do not

occur when the individual is not using substances. A person with a substance use problem

may begin taking unnecessary risks and may

Screening Instruments 503
act in an impulsive, dangerous manner.

Individuals who are intoxicated from substance

abuse may, for example, have sex with someone

in whom they ordinarily would not have a sexual interest, or they may start an argument or

fight.

Adverse consequences

Addiction invariably involves adverse consequences in numerous areas of an individual’s

life, including physical, psychological, and

social domains. In the screening instrument for

substance abuse, questions 5–9, 12, and 13 are

designed to elicit adverse consequences of substance abuse.

Examples of adverse physical consequences

resulting from substance abuse include experiencing blackouts, injury and trauma, or withdrawal symptoms or contracting an infectious

disease associated with high­risk sexual behaviors. One of the most serious health threats to

people with substance use disorders, particularly those who inject drugs intravenously, is

infection with HIV, the causative agent of

AIDS.

Adverse psychological consequences arising

from substance abuse include depression, anxiety, mood changes, delusions, paranoia, and

psychosis. Negative social consequences include

involvement in arguments and fights; loss of

employment, intimate relationships, and

friends; and legal problems such as civil lawsuits or arrests for abuse, possession, or selling

of illicit drugs.

As an individual’s use continues over time and

addiction takes hold, adverse consequences

tend to worsen. Thus, people in the very early

stages of addiction may have fewer adverse

consequences than those in the later stages.

Individuals in the early stages of addiction may

therefore not make the connection between

their substance abuse and the onset of negative

consequences. For this reason, some of the

items directed at identifying substance­related

adverse consequences in the screening instrument attempt to obtain this information without making an overt association with substance

abuse.

Problem recognition

Making a mental link between one’s use of substances and the problems that result from it—

such as difficulties in personal relationships or

at work—is an important step in recognizing

one’s substance abuse problem. Questions 2–4

and 13–16 in the substance abuse screening

instrument are problem recognition items.

Some of these items ask about past contacts

with intervention and treatment services,

because both research and clinical experience

indicate that a history of such contacts can be a

valid indicator of substance abuse problems.

Some individuals who have experienced negative consequences resulting from their substance abuse will report these problems during

a screening assessment. Clients who show

insight about the relationship between these

negative consequences and their use of substances should be encouraged to seek help.

Many, if not most, people who abuse substances, however, do not consciously recognize

that they have a problem. Other reasons why a

person may not disclose a substance abuse

problem include denial, lack of insight, and

mistrust of the interviewer. These individuals

cannot be expected to respond affirmatively to

“transparent” problem recognition items—

those in the form of direct questions, such as

“Do you have a substance problem?”—during

a screening interview. For these individuals,

questions must be worded indirectly in order to

ascertain whether negative experiences have

ensued from the use of substances.

Tolerance and withdrawal

Substance abuse, particularly prolonged abuse,

can cause a variety of physiological problems

that are related to the development of tolerance

and withdrawal. Questions 5 and 10 are aimed

at determining whether an individual has experienced any of the signs of tolerance and withdrawal.

504 Screening Instruments
Tolerance is defined as the need to use increasing amounts of a substance in order to create

the same effect. If tolerance has developed and

the individual stops using the substance of

abuse, it is common for withdrawal effects to

emerge.

Withdrawal from stimulants and related drugs

often includes symptoms of depression, agitation, and lethargy; withdrawal from depressants (including alcohol) often includes symptoms of anxiety, agitation, insomnia, and panic

attacks; and withdrawal from opioids produces

agitation, anxiety, and physical symptoms such

as abdominal pain, increased heart rate, and

sweating.

Administration of the Simple

Screening Instrument

Two versions of the simple screening instrument are presented in this section. They have

been designed to be administered in the form of

either an interview (Figure H­2, p. 506) or a

self­administered test (Figure H­3, p. 509) to

individuals who may be at risk of having a substance abuse problem.

Use of the screening instrument should be

accompanied by a careful discussion about confidentiality2 issues. The interviewer should also

be clear about the instrument’s purpose and

should make it understood that the information

elicited from the instrument will be used to

benefit, not to punish, the individual being

screened.

Ideally, the screening test should be administered in its entirety. Situations may arise, however, in which there is inadequate time to

administer the entire test. Street outreach community workers, for example, may have very

limited time with an individual.

In such situations, a subset of the screening

instrument can be administered. The four

boldfaced questions—1, 2, 3, and 16—constitute the short form of the screening instrument.

These items were selected because they represent the prominent signs and symptoms covered

by the full screening instrument. Although this

abbreviated version of the instrument will not

identify the variety of dimensions tapped by

the full instrument and is more prone to error,

it may serve as a starting point for the screening process.

Notes on the screening 

questions

The screening instrument begins with a question about the individual’s consumption of substances (question 1). This question is intended

to help the interviewer decide whether to continue with the interview—if the response to this

first question is no, continued questioning may

be unnecessary.

Questions 2–4 are problem recognition items

intended to elicit an individual’s assessment of

whether too much of a substance is being used,

whether attempts have been made to stop or

control substance use, and whether previous

treatment has been sought. Answers to these

questions may help the service provider understand how the individual thinks and feels about

his or her use of substances. People who later

report negative consequences as the result of

their substance use but who nevertheless

answer “no” to these problem recognition questions may have poor insight about their substance abuse or may be denying the severity of

their substance problem.

Questions 5–12 were designed to determine

whether an individual has experienced any

adverse consequences of substance abuse.

These include medical, psychological, social,

and legal problems that often are caused by

substance abuse and addiction. Some questions

are intended to elicit symptoms of aggression

2

Confidentiality is governed by the Federal “Confidentiality of Alcohol and Drug Abuse Patient Records” regulations (42

C.F.R. Part 2) and the Federal “Standards for Privacy of Individually Identifiable Health Information” (45 C.F.R.

Parts 160 and 164).

Screening Instruments 505
Figure H­2

Simple Screening Instrument for Substance Abuse Interview Form

Note: Boldfaced questions constitute a short version of the screening instrument that can be administered

in situations that are not conducive to administering the entire test. Such situations may occur because of

time limitations or other conditions.

Introductory statement:

“I’m going to ask you a few questions about your use of alcohol and other drugs during the past 6 months.

Your answers will be kept private. Based on your answers to these questions, we may advise you to get a

more complete assessment. This would be voluntary—it would be your choice whether to have an additional assessment or not.”

During the past 6 months...

1.	 Have you used alcohol or other drugs? (Such as wine, beer, hard liquor, pot, coke, heroin or

other opioids, uppers, downers, hallucinogens, or inhalants.) (yes/no)

2.	 Have you felt that you use too much alcohol or other drugs? (yes/no)

3.	 Have you tried to cut down or quit drinking or using drugs? (yes/no)

4.	 Have you gone to anyone for help because of your drinking or drug use? (Such as Alcoholics

Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program.)

(yes/no)

5.	 Have you had any of the following?

• Blackouts or other periods of memory loss

• Injury to your head after drinking or using drugs

• Convulsions, or delirium tremens (“DTs”)

• Hepatitis or other liver problems

• Feeling sick, shaky, or depressed when you stopped drinking or using drugs

• Feeling “coke bugs,” or a crawling feeling under the skin, after you stopped using drugs

• Injury after drinking or using drugs

• Using needles to shoot drugs

6.	 Has drinking or other drug use caused problems between you and your family or friends? (yes/no)

7.	 Has your drinking or other drug use caused problems at school or at work? (yes/no)

8.	 Have you been arrested or had other legal problems? (Such as bouncing bad checks, driving while

intoxicated, theft, or drug possession.) (yes/no)

9.	 Have you lost your temper or gotten into arguments or fights while drinking or using drugs?

(yes/no)

10. Are you needing to drink or use drugs more and more to get the effect you want? (yes/no)

11. Do you spend a lot of time thinking about or trying to get alcohol or other drugs? (yes/no)

12. When drinking or using drugs, are you more likely to do something you wouldn’t normally do, such

as break rules, break the law, sell things that are important to you, or have unprotected sex with

someone? (yes/no)

506 Screening Instruments
Figure H­2 (continued)

Simple Screening Instrument for Substance Abuse Interview Form

13. Do you feel bad or guilty about your drinking or drug use? (yes/no)

Now I have some questions that are not limited to the past 6 months.

14. Have you ever had a drinking or other drug problem? (yes/no)

15. Have any of your family members ever had a drinking or drug problem? (yes/no)

16.Do you feel that you have a drinking or drug problem now? (yes/no)

• Thanks for answering these questions.

• Do you have any questions for me?

• Is there something I can do to help you?

Notes: __________________________________________________________________________________

Observation Checklist

The following signs and symptoms may indicate a substance abuse problem in the individual being

screened:

• Needle track marks

• Skin abscesses, cigarette burns, or nicotine stains

• Tremors (shaking and twitching of hands and eyelids)

• Unclear speech: slurred, incoherent, or too rapid

• Unsteady gait: staggering, off balance

• Dilated (enlarged) or constricted (pinpoint) pupils

• Scratching

• Swollen hands or feet

• Smell of alcohol or marijuana on breath

• Drug paraphernalia such as pipes, paper, needles, or roach clips

• “Nodding out” (dozing or falling asleep)

• Agitation

• Inability to focus

• Burns on the inside of the lips (from freebasing cocaine)

Screening Instruments 507
(question 9), physical tolerance (question 10),

preoccupation (question 11), and loss of control (question 12). Question 13 is designed to

tap feelings of guilt, which may indicate that

the individual has some awareness or recognition of a substance problem; questions 14 and

16 are intended to measure the respondent’s

awareness of a past or present problem; and

question 15 elicits the individual’s family history of substance abuse problems.

Parenthetical words or phrases that accompany some of the screening questions are intended

to provide the interviewer with specific examples of what is being looked for or to help the

respondent understand the question. For

instance, question 1 asks whether an individual

has used substances, and the wording in parentheses prompts the administrator to ask about

specific substances of abuse.

Scoring and interpretation

A preliminary scoring mechanism for the

screening instrument is provided in Figure H­4,

p. 511.

Questions 1 and 15 are not scored, because

affirmative responses to these questions may

provide important background information

about the respondent but are too general for

use in scoring. The observational items are also

not intended to be scored, but the presence of

most of these signs and symptoms may indicate

a substance abuse problem.

It is expected that people with a substance

abuse problem will probably score 4 or more

on the screening instrument. A score of less

than 4, however, does not necessarily indicate

the absence of a substance abuse problem. A

low score may reflect a high degree of denial or

lack of truthfulness in the subject’s responses.

The scoring rules have not yet been validated,

and thus the substance abuse screening instrument needs to be used in conjunction with

other established screening tools when making

referrals.

Referral Issues

The substance abuse screening instrument, as a

first step in the process of assessment for substance abuse problems, can help service

providers determine whether an individual

should be referred for a more thorough assessment. When an individual with a potential substance abuse problem is identified through the

instrument, the interviewer has the further

responsibility of linking the individual to

resources for further assessment and treatment.

Agencies and providers using the substance

abuse screening instrument should be prepared

to make an appropriate referral when the

screening identifies a person with a possible

substance abuse problem. A phone number

written on a piece of paper is not likely to be

effective in linking the individual to the appropriate resource for assessment and treatment.

Rather, a thorough familiarity with local community resources is needed on the part of the

service provider. The referring provider should

take a proactive role in learning about the

availability of appointments or treatment slots,

costs, transportation needs, and the names of

contact people at the agencies to which referrals are made.

Because many individuals identified as having

possible substance abuse problems receive services from more than one agency, it is essential

that one agency assume primary responsibility

for the client. The ideal model is a case management system. Through personal contacts,

case managers can help patients progress

through various programs and systems, cut red

tape, and remove barriers to access to services.

Providing effective services for substance abuse

requires close cooperation among agencies.

Community linkages can help increase the

quality of treatment for patients, whereas

interagency competition decreases the quality

of comprehensive care.

Substance abuse problems should be seen within the larger context of other problems, both

current and past, confronted by the individual.

Current problems such as instability in housing

508 Screening Instruments
Figure H­3

Simple Screening Instrument for Substance Abuse Self­Administered Form

Directions: The questions that follow are about your use of alcohol and other drugs. Your answers will be

kept private. Mark the response that best fits for you. Answer the questions in terms of your experiences in

the past 6 months.

During the last 6 months...

1.	 Have you used alcohol or other drugs? (Such as wine, beer, hard liquor, pot, coke, heroin or other opioids, uppers, downers, hallucinogens, or inhalants)

___Yes ___ No

2.	 Have you felt that you use too much alcohol or other drugs?

___Yes ___ No

3.	 Have you tried to cut down or quit drinking or using alcohol or other drugs?

___Yes ___ No

4.	 Have you gone to anyone for help because of your drinking or drug use? (Such as Alcoholics

Anonymous, Narcotics Anonymous, Cocaine Anonymous, counselors, or a treatment program.)

___Yes ___ No

5.	 Have you had any health problems? For example, have you:

___

___

___

___

___

___

___

___

Had blackouts or other periods of memory loss?

Injured your head after drinking or using drugs?

Had convulsions, delirium tremens (“DTs”)?

Had hepatitis or other liver problems?

Felt sick, shaky, or depressed when you stopped?

Felt “coke bugs” or a crawling feeling under the skin after you stopped using drugs?

Been injured after drinking or using?

Used needles to shoot drugs?

6.	 Has drinking or other drug use caused problems between you and your family or friends?

___Yes ___ No

7.	 Has your drinking or other drug use caused problems at school or at work?

___Yes ___ No

Screening Instruments 509
Figure H­3 (continued)

Simple Screening Instrument for Substance Abuse Self­Administered Form

8.	 Have you been arrested or had other legal problems? (Such as bouncing bad checks, driving while

intoxicated, theft, or drug possession.)

___Yes ___ No

9.	 Have you lost your temper or gotten into arguments or fights while drinking or using other drugs?

___Yes ___ No

10. Are you needing to drink or use drugs more and more to get the effect you want?

___Yes ___ No

11. Do you spend a lot of time thinking about or trying to get alcohol or other drugs?

___Yes ___ No

12. When drinking or using drugs, are you more likely to do something you wouldn’t normally do, such as

break rules, break the law, sell things that are important to you, or have unprotected sex with someone?

___Yes ___ No

13. Do you feel bad or guilty about your drinking or drug use?

___Yes ___ No

The next questions are about your lifetime experiences.

14. Have you ever had a drinking or other drug problem?

___Yes ___ No

15. Have any of your family members ever had a drinking or drug problem?

___Yes ___ No

16. Do you feel that you have a drinking or drug problem now?

___Yes ___ No

Thanks for filling out this questionnaire.

and employment, homelessness, and hunger

often represent immediate needs that are more

pressing for the individual than treatment for

his or her substance abuse. Past crises, such as

incest, rape, and sexual abuse, can also affect

how an individual responds to the screening

questions.

Some of the items in the screening instrument

may trigger emotional distress or a crisis.

Reactions may sometimes include anxiety or

depression, which may be accompanied by suicidal thoughts and behaviors. Agencies should

therefore develop specific protocols to manage

such crises. These protocols should include

510 Screening Instruments
Figure H­4

Scoring for the Simple Screening Instrument for Substance Abuse

Name/ID No.: ____________________________________ Date: ________________________________

Place/Location: __________________________________________________________________________

Items 1 and 15 are not scored. The following items are scored as 1 (yes) or 0 (no):

___ 2 ___ 7 ___ 12

___ 3 ___ 8 ___ 13

___ 4 ___ 9 ___ 14

___ 5 (any items listed) ___ 10 ___ 16

___ 6 ___ 11

Total score: ____ Score range: 0­14

Preliminary interpretation of responses:

Score Degree of Risk for Substance Abuse

0­1 None to low

2­3 Minimal

>4 Moderate to high: possible need for further assessment

inhouse management and appropriate referrals

and followup.

See appendix C, Glossary, for substance abuse

screening terms.

Sources for the Substance

Screening Questions

Addiction Severity Index: McLellan, A.T.,

Luborsky, L., Woody, G.E., and O’Brien, C.P.

An improved diagnostic evaluation instrument

for substance abuse patients: The Addiction

Severity Index. Journal of Nervous and Mental

Disease 186:26–33, 1980.

AUDIT: Babor, T.F., De La Fuente, J.R., and

Saunders, J. AUDIT: Alcohol Use Disorders

Identification Test: Guidelines for Use in

Primary Health Care. Geneva: World Health

Organization, 1989.

CAGE: Mayfield, D., McLeod, G., and Hall, P.

The CAGE questionnaire: Validation of a new

alcoholism screening instrument. American

Journal of Psychiatry 131:1121–1123, 1974.

DAST: Skinner, H.A. Drug Abuse Screening

Test. Addictive Behavior 7:363–371, 1982.

DSM­III­R: American Psychiatric Association.

Diagnostic and Statistical Manual of Mental

Disorders, 3d Edition, Revised. Washington,

DC: American Psychiatric Association, 1987.

Screening Instruments 511
History of Trauma Scale: Skinner, H.A., Holt,

S., Schuller, R., Roy, J., and Israel, Y.

Identification of alcohol abuse using laboratory

tests and a history of trauma. Annals of

Internal Medicine 101:847–851, 1984.

MAST: Selzer, M.L. The Michigan Alcohol

Screening Test: The quest for a new diagnostic

instrument. American Journal of Psychiatry

127:1653–1658, 1971.

POSIT: Rahdert, E.R. The Adolescent

Assessment and Referral System Manual. HHS

Pub. No. (ADM) 91­1735. Rockville, MD:

National Institute on Drug Abuse, 1991.

RHSS: Fleming, M.F., and Barry, K.L. A

three­sample test of a masked alcohol screening

questionnaire. Alcohol 26:81–91, 1991.

512 Screening Instruments
Appendix I:

Selected Sources of

Training

Sources of Training on Addiction

Disorders

Addiction Technology Transfer Centers (ATTCs)

Check with your local ATTC. Course offerings vary.

• http://www.nattc.org

• For curricula, lectures, videos, and printed training materials available through ATTCs, see http://www.nattc.org/resPubs.html

• For information on distance training offered by ATTCs and other

providers, see http://www.addictionED.org

Hazelden Institute

Hazelden offers training opportunities at many levels and locations.

The Graduate School of Addiction Studies offers both a Master of Arts

in Addiction Studies and individualized programs. A Chemical

Dependency Counselor Certificate program is available for those with

less formal training. Contact the Graduate School at (888) 257­7800, ext.

4175 for more information.

The Hazelden Distance Learning Center for Addiction Studies provides

opportunities for home­based study. Courses may be taken via the Web

or using traditional print materials. Contact the Distance Learning

Center at (800) 328­9000 for more information.

513
National Association for

Alcohol and Drug Abuse

Counselors (NAADAC)

The NAADAC Web site includes lists of

approved education providers, distance learning opportunities, and post­secondary programs. Home study materials are also available

through NAADAC. Contact: (800) 548­0497.

National Clearinghouse for

Alcohol and Drug Information

(NCADI)

The Substance Abuse and Mental Health

Services Administration’s (SAMHSA’s) NCADI

distributes materials developed by SAMHSA’s

Center for Substance Abuse Prevention and

Center for Substance Abuse Treatment, along

with several other agencies. Contact NCADI at

(800) 729­6686 for more information.

National Institute on Alcohol

Abuse and Alcoholism

(NIAAA)

Project Matching Alcoholism Treatment to

Client Heterogenity (MATCH) manuals are the

result of the collaborative efforts of the Project

MATCH investigators and are used as guides

by the therapists in the trial. They are presented to the alcohol research community as standardized, well­documented intervention tools

for alcoholism treatment research. The manuals address 12­Step facilitation, motivational

enhancement, and cognitive–behavioral treatments.

• To access Project MATCH materials,

write to:
 

National Institute on Alcohol Abuse and
 

Alcoholism
 

Publications Distribution Center
 

P.O. Box 10686
 

Rockville, MD 20849­0686
 

National Institute on Drug

Abuse (NIDA)

NIDA publishes a wide variety of treatmentrelated materials, including a three­volume set

of therapy manuals for cocaine addiction.

Contact: (301) 443­1124.

National Development and

Research Institutes, Inc. (NDRI)

NDRI offers an extensive training program of

75 courses in substance abuse and HIV/AIDS,

consultation, and technical assistance for program development and implementation.

Contact: (212) 846­4566.

Other University-Based

Training

A number of universities offer training. For

example, the Division on Addictions at

Harvard Medical School offers a fellowship in

addictions and other training for counselors,

MSWs, and other clinicians.

Rutgers Center for Alcohol

Studies

The Center for Alcohol Studies offers two types

of programs through its Education and

Training Division. Both the School of Alcohol

and Drug Studies and the Institute of Alcohol

and Drug Studies offer weeklong programs

throughout the summer months for interested

professionals and laypersons. During the academic year, professionals may choose 1­day

courses from the Continuing Professional

Education Seminars. Contact the Center’s

Education and Training Division at (732) 445­

4317 for more information.

514 Selected Sources of Training
State Certifying Boards for

Chemical Dependency

Counseling

A list of individual State boards is available

through NAADAC. Contact: (800) 548­0497.

Another list is available through the

International Certification and Reciprocity

Consortium. Contact: (919) 572­6823.

Sources of Training on

Mental Health

American Counseling

Association

Home study courses, learning institutes, and

onsite training. Contact: (703) 823­9800.

American Psychological

Association

Office of Continuing Professional Education.

Home study and other approved courses,

including some co­occurring disorder specific

offerings. Contact: (202) 336­5991.

American Psychiatric

Association

Office of Continuing Medical Education. Gives

CME credits for review and exam based on the

Association’s annual meeting. Ask for a listing

of other conferences and courses available for

CME credits. Contact: (202) 682­6179.

National Mental Health

Information Center (NMHIC)

This is a service of SAMHSA’s Center for

Mental Health Services. NMHIC distributes

materials developed by the Center for Mental

Health Services and other agencies. Several

training manuals are among the publications

offered. Contact NMHIC at (800) 789­2647 for

more information.

National Institute of Mental

Health (NIMH)

NIMH provides a variety of manuals and

research reports, including texts on anxiety disorders and depression. Contact: (301) 443­4513.

Sources of Training on

Co­Occurring Disorders

Addiction Technology Transfer

Centers (ATTCs)

Check with your local ATTC. Course offerings

vary.

• For distance training offered by ATTCs and

other providers, see

http://www.addictionED.org

• For curricula, lectures, videos, and printed

training materials:

http://www.nattc.org/resPubs.html (search

for co­occurring disorders)

Formal Continuing Education

COD Curricula

Several examples follow:

Dual Recovery Project

Houston Community College, University of

Houston, Harris County MHMRA, Houston,

Texas. Contact: (713) 970­7000.

Selected Sources of Training 515
Integrated Program

Development and Clinical

Interventions

Foundations Associates and the Dual Diagnosis

Recovery Network in Nashville, TN provide

specialized training on implementation and

financing of integrated program models and

integrated clinical interventions. Contact: (888)

869­9230.

MISA Curriculum

Seven modules, Behavioral Healthcare

Resource Program, University of North

Carolina, School of Social Work. Contact:

(919) 962­1225.

National Development and

Research Institutes

NDRI has a COD Curriculum with 10 modules

targeting the generalist. Contact: (646) 638­

2497.

Washington State Institute

for Mental Health Research

and Training

The institute has extensive training materials

as well as training videotapes on COD.

Contact: (253) 756­2741.

Miscellaneous Training

A variety of training opportunities are listed by

Kathleen Sciacca at

State­Sponsored Training

Many States have developed model curricula.

Listservs and

Discussion Groups on

Co­Occurring Disorders

The following is a selection of listservs and

discussion groups dealing specifically with the

topic of co­occurring disorders. These online

communication networks offer members the

opportunity to post suggestions or questions

to a large number of people at the same time.

Listservs differ in that they are generally

geared more toward professionals and are

more closely monitored. Discussion groups

are usually open to anyone, and may not be

closely monitored. Submissions to listservs

are distributed to all members, so before submitting a query or a comment to an entire

listserv group, you may wish to monitor the

discussions. 

CataList—The Official Catalog

of Listserv Lists

CataList, a general resource, is a catalog of

more than 55,000 listserv lists. It allows users

to browse listserv lists, search by keyword for

mailing lists of interest, and obtain information

about listserv host Web sites. CataList contains

information only about public lists; confidential

lists and lists of purely local interest are not in

the searchable database.

516 Selected Sources of Training
This discussion list belongs to the field.

Membership is open, but the list is moderated,

and CSAT reserves the right to remove any

member who the agency feels is not interacting

in a professional manner. Co­Occurring

Dialogues is offered as a means of communication, idea sharing, brainstorming, sharing of

exciting publications and opportunities, etc. It

is an open vehicle for communication between

and among researchers, educators, treatment

agencies, the recovery community, treatment

providers, and all levels of government.

Dual Diagnosis Bulletin

Board

This subdivision of the Dual Diagnosis Listserv

is a more general discussion area. Visitors can

review postings on the bulletin board by clicking on headings of interest, and/or submit

information for posting to the bulletin board.

This area is open to anyone, consumers as well

as professionals, and is not moderated.

Dual Diagnosis Listserv

This listserv is operated by Dr. Kathleen

Sciacca, Founding Executive Director of

Sciacca Comprehensive Service Development

for Mental Illness, Drug Addiction and

Alcoholism (MIDAA), located in New York

City. The listserv is an extension of the Dual

Diagnosis Web site, and is reserved for persons

who are credentialed in the mental health and

substance abuse fields and have an interest in

the theory, practice, treatment, systemic

change, and program implementation for

dual/multiple disorders in various combinations. A resume or curriculum vitae must be

submitted in order to subscribe. Membership is

determined at the discretion of the list manager. Once credential information is received,

members will receive a welcome message

informing them of acceptance to the list and

instructions on how to post to the forum.

Dual Diagnosis Pages:

Colleagues List

The Colleagues List is a division of The Dual

Diagnosis Pages (no longer active as of 2012

update), a general resource Web site for cooccurring addiction and personality disorders.

The Colleagues List allows professionals to act

as mutually supporting resources. Mental

health and substance abuse treatment professionals can post a description of themselves and

their qualifications/background so that practitioners with common interests, issues, or questions can get in touch with each other.

MIDAS: Discussion Group

MIDAS is a member of the Dual Disorder Web

Ring, and offers a Discussion Group (no longer

active as of 2012 TIP update) through

IDAS is an Australian site provided by the South Western Sydney Area

Health Service, but it offers links to programs

and resources around the world. There are no

special conditions for joining the Discussion

Group, and new members are joining all the

time. However, the description given on the

home page freely acknowledges that the group

gets active only from time to time, sometimes

slowing down for months.

Yahoo.com. M

Selected Sources of Training 517
Appendix J: 

Dual Recovery Mutual

Self-Help Programs and

Other Resources for

Consumers and Providers

Dual Recovery 12­Step Fellowships

Double Trouble in Recovery

The organization provides 12 steps that are based on a traditional adaptation of the original 12 steps. For example, the identified problem in

step one is changed to co­occurring disorders, and the population to be

assisted is changed in step 12 accordingly. The organization provides a

format for meetings that are chaired by members of the fellowship.

Contact information

Double Trouble in Recovery

c/o Mental Health Empowerment Project

271 Central Avenue

Albany, NY 12209

(518) 434­1393

Dual Diagnosis Anonymous

The organization provides a hybrid approach that developed 5 steps in

conjunction with the traditional 12 steps. The five steps differ from those

of other dual recovery groups in underscoring the potential need for

medical management, clinical interventions, and therapies. The organization provides a meeting format that is used by fellow members who

chair the meetings.

Contact information

Dual Diagnosis Anonymous

320 North E. Street, Suite 207

San Bernardino, CA 92401

(909) 888­9282

519
Dual Disorders Anonymous

The organization provides 12 steps that are

based on a traditional adaptation of the original 12 steps. For example, the identified problem in step one is changed to co­occurring disorders, and the population to be assisted is

changed in step 12 accordingly. The organization provides a format for meetings that are

chaired by members of the fellowship.

Contact information

Dual Disorders Anonymous

P.O. Box 681264

Schaumburg, IL 60168

(847) 781­1553

Dual Recovery Anonymous

The organization provides 12 steps that are an

adapted and expanded version of the traditional 12 steps. The expanded approach changes

the identified problem to co­occurring disorders, and the population to be assisted is

changed accordingly. It also retains most of the

traditional language while modifying certain

terms in an effort to meet the needs of mental

health consumers. In addition, it incorporates

affirmations into three of the 12 steps. The

organization provides a meeting format that is

used by fellow members who chair the meetings.

Contact information

Dual Recovery Anonymous World Services,

Inc.

P.O. Box 8107

Prairie Village, KS 66208

(877) 883­2332 (toll free)

Dual Recovery Empowerment

Foundation

This organization offers the program Dual

Recovery Self­Help, which encompasses information on dual recovery 12­Step fellowships;

12­Step principles for personal recovery, coping, and life skills; and forming dual recovery

12­Step groups and meetings.

Contact information

Dual Recovery Empowerment Foundation

P.O. Box 8708

Prairie Village, KS 66208

(615) 504­9797

rwth@kc.rr.com

Supported Mutual

Help for Dual Recovery

Dual Diagnosis Recovery

Network (DDRN)

The DDRN is a program of Foundations

Associates that derives part of its funding from

the Tennessee Department of Mental Health

and Developmental Disabilities, as well as the

Tennessee Department of Health, Bureau of

Alcohol and Drug Abuse Services. DDRN provides dual recovery mutual help information in

all areas of the services that are offered; education and training through community programs, inservice training, workshops, State,

regional, and national conferences; advocacy

and coalition building through networking and

coordinating a statewide task force that engages

chemical dependency and mental health professionals, consumers, and family members; provides information through the Dual Network

quarterly journal and the resource and information clearinghouse.

520 Dual Recovery Mutual Self­Help Programs and Other Resources for Consumers and Providers
Contact information

Dual Diagnosis Recovery Network (DDRN)

220 Venture Circle

Nashville, TN 37228

(888) 869­9230

Support Together for

Emotional/Mental Serenity

and Sobriety (STEMSS)

STEMSS is a psychoeducational group intervention. The model has been developed to train

facilitators to initiate, implement, and maintain

support groups for consumers. The six steps of

the program and the support groups are

intended to complement participation in traditional 12­Step programs.

Contact information

Michael G. Bricker, Executive Director

STEMSS Institute and Bricker Clinic

140 E. Dekora Street

Saukville, WI 53080

(414) 268­0899

Other Resources for

Consumers and

Providers

Consumer Organization and

Networking Technical

Assistance Center (CONTAC)

CONTAC distributes a list of names and contacts for resources and information on substance addictions, co­occurring disorders, services, and mutual help support. CONTAC also

offers the Leadership Academy, a training program that is designed to help consumers learn

how to engage in and develop consumer services. Recently, a training component focusing

on substance abuse/dependence was developed

and incorporated into the program.

Contact information

Consumer Organization and Networking

Technical Assistance Center (CONTAC)

1036 Quarrier Street, Suite 208A

Charleston, WV 25891

(304) 346­9992 or (888) 825­8324

National Council on

Alcoholism and Drug Dependence (NCADD)

NCADD has a nationwide network of nearly

100 affiliates. These affiliates provide information and referrals to local services, including

counseling and treatment. NCADD also offers a

variety of publications and resources.

Contact information

NCADD National Office

20 Exchange Place, Suite 2902

New York, NY 10005

(212) 269­7797

Fax: (212) 269­7510

National Empowerment

Center

The National Empowerment Center has prepared an information packet, which includes a

series of published articles, newspaper articles,

and a listing of organizations and Federal agencies that provide information, resources, and

technical assistance related to substance abuse

and dependence, co­occurring disorders, services, and mutual help support.

Contact information

National Empowerment Center

599 Canal Street

Lawrence, MA 01840

(800) 769­3728

Dual Recovery Mutual Self­Help Programs and Other Resources for Consumers and Providers 521
National Mental Health

Association

The National Mental Health Association has

expanded its mission to encompass substance

abuse/addictions and co­occurring disorders.

The organization continues to develop

resources, documents, and publications. A designated section on the organization’s Web site is

dedicated to co­occurring disorders.

Contact information

National Mental Health Association

1021 Prince Street

Alexandria, VA 22314­2971

(800) 969­6642

TTY: (800) 433­5959

National Mental Health

Consumers’ Mutual Help

Clearinghouse

The organization has developed and offers a

resource kit, which provides the names and

contacts for resources and information on substance addictions, co­occurring disorders, services, and mutual help support.

Contact information

National Mental Health Consumers’ Self­Help

Clearinghouse

1211 Chestnut Street, Suite 1207

Philadelphia, PA 19107

(800) 553­4KEY

522 Dual Recovery Mutual Self­Help Programs and Other Resources for Consumers and Providers
Appendix K:

Confidentiality

Federal Laws and the Right to

Confidentiality

In the early 1970s, Congress recognized that the stigma associated with

substance abuse and fear of prosecution deterred people from entering

treatment. As a result, it enacted legislation that gave clients in a substance abuse treatment program a right to confidentiality (42 USC

§290dd­2). For the 3 decades since the Federal confidentiality regulations (42 C.F.R. Part 2, or Part 2) were issued in response to the Federal

mandate, confidentiality has been a cornerstone practice for substance

abuse treatment programs across the country.

In December 2000, the Department of Health and Human Services

(HHS) issued the “Standards for Privacy of Individually Identifiable

Health Information” final rule (Privacy Rule), pursuant to the

Administrative Simplification provisions of the Health Insurance

Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. Parts

160 and 164, Subparts A and E. Substance abuse treatment programs

that are subject to HIPAA must comply with the Privacy Rule. The

Privacy Rule and other guidance regarding its requirements may be

accessed through the HHS Office for Civil Rights (OCR) Web site. In

addition, the Substance Abuse and Mental Health Services

Administration (SAMHSA) has issued guidance titled “The

Confidentiality of Alcohol and Drug Abuse Patient Records Regulation

and the HIPAA Privacy Rule: Implications for Alcohol and Substance

Abuse Programs,” which can be accessed through its Web site.

How the Two Federal Laws Relate to Each

Other and to State Law

Substance abuse treatment programs need to understand how both

Federal laws—the older substance abuse­specific Part 2 regulations and

the Privacy Rule—apply to their programs.

523
Applicability

Part 2

Part 2 applies to all programs (individuals or

organizations) specializing, in whole or in part,

in providing treatment, counseling, or assessment and referral services for substance use

disorders (§§2.11, 2.12(e)). (Any citations in

this appendix that begin with §2 refer to sections of 42 C.F.R. Part 2.) Part 2 applies only

to programs that receive Federal assistance,

including indirect forms of Federal aid, such as

tax­exempt status or State or local government

funding that is from (in whole or in part) the

Federal government or any form of Medicaid

or Medicare funding for any purpose.

Privacy Rule

The Privacy Rule applies to healthcare

providers (persons or organizations that furnish, bill, or are paid for health care in the

normal course of business) who transmit health

information

• In electronic form (generally, via computerbased technology) and

• In connection with transactions for which

HHS has adopted a HIPAA standard, such

as submitting healthcare claims to Medicaid

or private payors.

Drug and alcohol programs are healthcare

providers because they furnish health care in

the normal course of business. However, only

those programs that transmit health information in electronic form and in connection with a

HIPAA transaction, such as a healthcare claim,

are subject to the Privacy Rule (such programs, along with health plans and healthcare

clearinghouses, are HIPAA “covered entities”).

(For a list of the HIPAA transactions for which

standards have been adopted, see 45 C.F.R.

Part 162. Note that once a program is subject

to HIPAA, all “protected health information”

[see below] that the program transmits or

maintains about individuals is covered by the

Privacy Rule—whether the information is in

oral, written, or electronic form.)

Information protected

Part 2 requirements

The Part 2 requirements

• Apply to information about any individual

who has applied for or received any substance­abuse–related assessment, treatment,

or referral services and prohibit all disclosures of information about that person that

are not specifically permitted by nine limited

exceptions.

• Are more restrictive of communications in

many instances than either the

doctor–patient or the attorney–client privilege.

• Apply to information about current and former clients from the time they make an

appointment and apply to any information

that would identify them as individuals who

use substances either directly or by implication.

• Apply to information about clients who are

mandated into treatment as well as to information about those who enter treatment voluntarily.

• Apply whether the person seeking information already has that information, has other

ways of getting it, has some form of official

status, is authorized by State law, or comes

armed with a subpoena or search warrant.

• Violating Part 2 is punishable by a fine of up

to $500 for a first offense and up to $5,000

for each subsequent offense (§2.4).

Privacy Rule requirements

Under the Privacy Rule, a program may not

use or disclose protected health information

except as permitted or required by the Rule.

See 45 C.F.R. §164.502(a). Protected health

information is defined as individually identifiable health information held or transmitted by

a covered entity or its “business associate,”

with limited exceptions. See 45 C.F.R.

§160.103. It does not include such information

in employment records or in certain educational records. The Privacy Rule permits disclosures in many circumstances in which Part 2

would not. Most importantly, the Privacy Rule

524 Confidentiality
does not require that the client consent to disclosures made for “treatment, payment or

health care operations” (§§164.502(a)(1)(ii);

164.506(c)). (Citations in the form §164. . .

refer to sections in 45 C.F.R. Part 164.) Part 2

requires client consent for almost all such disclosures. There are civil and criminal penalties

for violations of the Privacy Rule.

State laws and regulations

Covered entities will usually be able to comply

with both Privacy Rule and applicable State

law provisions. However, there may be situations in which the provisions of the Privacy

Rule and State law are contrary, which generally means the covered entity would find it

impossible to comply with both. If contrary, the

Privacy Rule overrides State law, unless the

State law is more stringent; that is, unless the

State law provides greater privacy protection

for the individual who is the subject of the protected health information. If the State law is

more stringent, programs must comply with the

State law. A Privacy Rule provision would also

not prevail over a contrary State law provision

where HHS had granted an exception.

Working with both sets of

regulations

Substance abuse treatment programs that are

already complying with Part 2 should not have

a difficult time complying with the Privacy

Rule, as it parallels the requirements of Part 2

in many areas. Programs subject to both sets of

rules must comply with both, unless there is a

conflict between them. Generally, this will

mean that substance abuse treatment programs

should continue to follow Part 2. In some

instances, programs will have to establish new

policies and procedures or alter existing policies and procedures.

Security of records 

Part 2 requires programs to maintain written

records in a secure room, a locked file cabinet,

a safe, or other similar container. It requires

programs to adopt written procedures to regulate access to and use of clients’ records. Either

the program director or a single staff person

should be designated to process inquiries and

requests for information (§2.16).

Section 164.530(c) of the Privacy Rule requires

programs that are covered entities to maintain

reasonable and appropriate administrative,

technical, and physical safeguards to protect

the privacy of protected health information.

The issue of security is addressed in more

detail through a separate Security Rule issued

by HHS on February 20, 2003, that establishes

the administrative, physical, and technical

safeguards required to guard the integrity, confidentiality, and availability of protected health

information that is electronically stored, maintained, or transmitted. See 45 C.F.R. §164.306.

Alcohol and substance abuse programs that are

covered entities must be in compliance with the

Security Rule by April 20, 2005. The Security

Rule can be accessed through the Centers for

Medicare and Medicaid Services Web site.

More information can be obtained from

the technical assistance publication “The

Confidentiality of Alcohol and Drug

Abuse Patient Records Regulation and

the HIPAA Privacy Rule: Implications

for Alcohol and Substance Abuse Programs.”

For printed copies, contact SAMHSA’s Health

Information Network at (800) 729­6686 or

(301) 468­2600; TDD (for hearing impaired)

(800) 487­4889.

Confidentiality 525
Appendix L: 

Resource Panel 

Robert E. Anderson

Director

Research and Program Applications

National Association of State Alcohol and Drug Abuse Directors

Washington, DC

Nancy Bateman, LCSW­C, CAC

Senior Staff Associate

Division of Professional Development and Advocacy

National Association of Social Workers

Washington, DC

James F. Callahan, D.P.A.

Executive Vice President

American Society of Addiction Medicine

Chevy Chase, Maryland

Frank Canizales, M.S.W.

Management Analyst, Alcohol Program

Division of Clinical and Preventive Services

Indian Health Service

Rockville, Maryland

Cathi Coridan, M.A.

Senior Director for Substance Abuse Programs and Policy

National Mental Health Association

Alexandria, Virginia

Jennifer Fiedelholtz

Public Health Analyst

Office of Policy and Program Coordination

Substance Abuse and Mental Health Services Administration

Rockville, Maryland

527
Ingrid D. Goldstrom, M.Sc.

Center for Mental Health Services

Rockville, Maryland

Lynne M. Haverkos, M.D., M.P.H.

Program Director

Behavioral Pediatrics and Health Promotion

Research Program
 

National Institute of Child Health and
 

Human Development
 

Bethesda, Maryland
 

Edward Hendrickson, LMFT, MAC

Clinical Supervisor

Arlington County Mental Health and

Substance Abuse Services Division
 

Arlington, Virginia
 

Kevin D. Hennessy, Ph.D.

Senior Health Policy Analyst

Office of the Assistant Secretary

for Planning and Evaluation

Department of Health and Human Services

Washington, DC

James (Gil) Hill, Ph.D.

Director

Office of Rural Health and Substance Abuse

American Psychological Association

Washington, DC

Hendree E. Jones, Ph.D.

Assistant Professor

Department of Psychiatry and Behavioral

Sciences
 

Johns Hopkins University Center
 

Baltimore, Maryland
 

Diane M. Langhorst

Clinical Supervisor

Substance Abuse Services

Henrico Area Mental Health

and Retardation Services
 

Richmond, Virginia
 

Tom Leibfried, M.P.A.

Vice President of Government Relations

National Council for Community Behavioral

Healthcare
 

Rockville, Maryland
 

James J. Manlandro, D.O.

Director

Family Addiction Treatment Services, Inc.

Dennisville, New Jersey

Julia W. Maxwell, L.I.C.S.W., C.A.S.

Branch Director

Mental Health Addiction and Services

Branch

Commission on Mental Health Services

District of Columbia

Washington, DC

William F. Northey, Jr., Ph.D.

Research Specialist

American Association for Marriage and

Family Therapy
 

Alexandria, Virginia
 

Fred C. Osher, M.D.

Director

Center for Behavioral Health, Justice

and Public Policy
 

University of Maryland
 

Jessup, Maryland
 

Terry C. Pellmar, Ph.D.

Director

Board on Neuroscience and Behavioral

Health
 

Institute of Medicine
 

Washington, DC
 

Ernst Quimby, Ph.D.

Associate Professor

Department of Sociology

and Anthropology
 

Howard University
 

Washington, DC
 

Susan E. Salasin

Director

Mental Health and Criminal Justice

Program
 

Center for Mental Health Services
 

Rockville, Maryland
 

Laurel L. Stine, J.D., M.A.

Director of Federal Relations

Bazelon Center for Mental Health Law

Washington, DC

528 Resource Panel
Richard T. Suchinsky, M.D.

Associate Director for Addictive Disorders

and Psychiatric Rehabilitation

Mental Health and Behavioral Sciences

Services

Department of Veterans Affairs

Washington, DC

Jan Towers, Ph.D., CRNP

Director

Health Policy

American Academy of Nurse Practitioners

Washington, DC

Steve Wing

Senior Advisor for Drug Policy

Office of Policy and Program Coordination

Substance Abuse and Mental Health

Services Administration

Rockville, Maryland

Resource Panel 529
Appendix M: 

Cultural Competency

and Diversity Network

Participants

Raymond Daw, M.A.

Executive Director

Na’nizhoozhi Center, Inc.

Gallup, New Mexico

Disabilities Work Group

Michael I. Fingerhood, M.D., FACP

Associate Professor

Department of Medicine

Center for Chemical Dependence

School of Medicine

Johns Hopkins Bayview Medical Center

Baltimore, Maryland

Aging Work Group

Ting­Fun May Lai, M.S.W., CSW, CASAC

Director

Chinatown Alcoholism Center

Hamilton­Madison House

New York, New York

Asian and Pacific Islanders Work Group

Antony P. Stephen, Ph.D.

Executive Director

Mental Health & Behavioral Sciences

New Jersey Asian American Association for Human Services, Inc.

Elizabeth, New Jersey

Asian and Pacific Islanders Workgroup

531
Richard T. Suchinsky, M.D.

Associate Chief for Addictive Disorders

and Psychiatric Rehabilitation

Mental Health and Behavioral Sciences

Services
 

Department of Veterans Affairs
 

Washington, DC
 

Disabilities Work Group
 

Ann S. Yabusaki, Ph.D.

Director

Coalition for a Drug­Free Hawaii

Honolulu, Hawaii

Asian and Pacific Islanders Work Group

532 Cultural Competency and Diversity Network Participants
Appendix N:

Field Reviewers

Calvin Baker

Addicted Homeless Project

Program Coordinator

Division of Addictions and Mental Health

Prince George’s County Health Department

Forestville, Maryland

Richard J. Bilangi, M.S.

Executive Director/President

Connecticut Counseling Centers, Inc.

Middlebury, Connecticut

Dennis L. Bouffard, Ph.D.

Program Manager

Connecticut Valley Hospital

Addiction Services Division

Middletown, Connecticut

Kim P. Bowman, M.S.

Executive Director

Chester County Department of Drug and Alcohol Services

West Chester, Pennsylvania

Patricia Hess Bridgman, M.A., CCDC III­E

Associate Director

Ohio Council of Behavioral Healthcare Providers

Columbus, Ohio

Barry S. Brown, Ph.D.

Adjunct Professor

University of North Carolina at Wilmington

Carolina Beach, North Carolina

533
Vivian B. Brown, Ph.D.

President/Chief Executive Officer

PROTOTYPES

Culver City, California

Tamara J. Cadet, M.S.W., MPH

Web Content Manager

Free to Grow: Head Start Partnerships to

Promote Substance­Free Communities
 

Columbia University
 

Andover, Massachusetts
 

Sharon M. Cadiz, Ed.D.

Senior Director of Special Projects

Project Return Foundation, Inc.

New York, New York

Jerome F.X. Carroll, Ph.D.

Private Practice

Brooklyn, New York

Bruce Carruth, Ph.D., LCSW

Private Practice

Laredo, Texas

Michael Cartwright, Ph.D.

Executive Director

Foundations Associates

Nashville, Tennessee

Catherine S. Chichester, M.S.N., R.N., CS

Executive Director

Co­Occurring Collaborative of Southern

Maine
 

Portland, Maine
 

Carol Coley, M.S., CAPT, USPHS

Senior Program Management Advisor

Division of State and Community Assistance

Systems Improvement Branch

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services

Administration

Rockville, Maryland

Margaret A. Cramer, Ph.D.

Clinical Psychologist/Instructor

Melrose, Massachusetts

George De Leon, Ph.D.

Director

Center for Therapeutic Community Research

National Development and Research

Institutes, Inc.
 

New York, New York
 

Janice M. Dyehouse, Ph.D., R.N., M.S.N.

Professor and Department Head

College of Nursing

University of Cincinnati

Cincinnati, Ohio

Benjamin M. Eiland, M.A., CATS, EAP

Director of Substance Abuse Services

Haight Ashbury Free Clinic

San Francisco, California

Dorothy J. Farr

Clinical Director

Bucks County Drug and Alcohol

Commission, Inc.
 

Warminster, Pennsylvania
 

Michael I. Fingerhood, M.D., FACP

Associate Professor

Department of Medicine

Center for Chemical Dependence

School of Medicine

Johns Hopkins Bayview Medical Center

Baltimore, Maryland

Jerry P. Flanzer, D.S.W., LCSW, CAC

Chief, Services

Division of Clinical and Services Research

National Institute on Drug Abuse

Bethesda, Maryland

Byron N. Fujita, Ph.D.

Senior Psychologist

Clackamas County Mental Health Center

Oregon City, Oregon

Gerard Gallucci, M.D., M.H.S.

Medical Director

Community Psychiatry Program

Bayview Medical Center

Johns Hopkins University

Baltimore, Maryland

534 Field Reviewers
Mary Gillespie, Psy.D., CASAC

Psychologist

Saratoga Springs, New York

Karen Scott Griffin, M.S.

Director of Administration

Gaudenzia, Inc.

Norristown, Pennsylvania

Valerie A. Gruber, Ph.D., M.P.H.

Assistant Clinical Professor

University of California, San Francisco

San Francisco, California

Nancy Handmaker, Ph.D.

Professor

Department of Psychology

The University of New Mexico

Albuquerque, New Mexico

Edward Hendrickson, LMFT, MAC

Clinical Supervisor

Arlington County MHSASD

Arlington, Virginia

David Hodgins, Ph.D.

Professor

Department of Psychology

University of Calgary

Calgary, Canada

Kimberly A. Johnson

Director

Maine Office of Substance Abuse

Augusta Mental Health Complex

Augusta, Maine

Edith Jungblut

Public Health Advisor

Center for Substance Abuse Treatment

Substance Abuse and Mental Health Services

Administration

Rockville, Maryland

George A. Kanuck

Public Health Analyst

Co­Occurring and Homeless Branch

Division of State and Community Assistance

Center for Substance Abuse Treatment

Rockville, Maryland

Michael W. Kirby, Jr., Ph.D.

Chief Executive Officer

Arapahoe House, Inc.

Thornton, Colorado

Daniel R. Kivlahan, Ph.D.

Director

VA Center of Excellence in Substance Abuse

Treatment and Education
 

VA Puget Sound Health Care System
 

Seattle, Washington
 

Ting­Fun May Lai, M.S.W., CSW, CASAC

Director

Chinatown Alcoholism Services

New York, New York

Linda Lantrip, D.O., R.N.

Medical Director

Central Oklahoma Community

Mental Health Center

Norman, Oklahoma

Robert M. Long, M.S., LCDC, LADC

Director of Substance Abuse and Dual

Diagnosis Services
 

Kennebee Valley Mental Health Center
 

Augusta, Maine
 

Russell P. MacPherson, Ph.D., CAP, CAPP,

CCP, CDVC, DAC
 

President
 

RPM Addiction Prevention Training
 

Sanford, Florida
 

Philip R. Magaletta, Ph.D.

Clinical Training Coordinator

Federal Bureau of Prisons

Washington, DC

G. Alan Marlatt, Ph.D.

Professor of Psychology

Director, The Addictive Behaviors

Research Center
 

University of Washington
 

Seattle, Washington
 

Field Reviewers 535
Julia W. Maxwell, LICSW, CAS

Branch Manager

Department of Mental Health/

Community Services
 

Mental Health and Addiction Services
 

St. Elizabeth’s Campus
 

Washington, DC
 

Frank A. McCorry, Ph.D.

Director

Clinical Services Unit

N.Y.S. Office of Alcoholism and Substance

Abuse Services
 

New York, New York
 

Gregory J. McHugo, Ph.D.

Research Associate Professor

Dartmouth Medical School

NH­Dartmouth Psychiatric Research Center

Lebanon, New Hampshire

David Mee­Lee, M.D., FASAM

DML Training and Consulting

Davis, California

Kenneth Minkoff, M.D.

Medical Director

Choate Health Management

Woburn, Massachusetts

Theresa Moyers, Ph.D.

Assistant Research Professor

Department of Psychology

University of New Mexico

Albuquerque, New Mexico

Ethan Nebelkopf, Ph.D., MFCC

Clinic Director

Family and Child Guidance Center

Native American Health Center

Oakland, California

Gwen M. Olitsky, M.S.

Chief Executive Officer

The Self­Help Institute for Training and

Therapy
 

Lansdale, Pennsylvania
 

Thomas A. Peltz, M.Ed., LMHC, CAS

Therapist

Private Practice

Beverly Farms, Massachusetts

Stephanie W. Perry, M.D.

Assistant Commissioner of Health

Bureau of Alcohol and Drug Abuse Services

Tennessee Department of Health

Nashville, Tennessee

Lawrence D. Rickards, Ph.D.

Co­Occurring Disorders Program Manager

Homeless Programs Branch

Center for Mental Health Services

Substance Abuse and Mental Health Services

Administration

Rockville, Maryland

Jeffery L. Rohacek, M.S., CASAC

Psychologist II

McPike Addiction Treatment Center

Utica, New York

Edwin M. Rubin, Psy.D.

Psychologist

Aurora Behavioral Health Services

Aurora Health Care

Milwaukee, Wisconsin

Theresa Rubin­Ortiz, LCSW

Clinical Director

Bonita House, Inc.

Oakland, California

Margaret M. Salinger, M.S.N., R.N., CARN

Unit/Program Manager

Coatesville VA Medical Center

Coatesville, Pennsylvania

Steven V. Sawicki

Assistant Program Director

Center for Human Development

Connecticut Outreach­West

Waterbury, Connecticut

Anna M. Scheyett, M.S.W., LCSW, CASWCM

Clinical Assistant Professor

School of Social Work

University of North Carolina

Chapel Hill, North Carolina

536 Field Reviewers
Marilyn S. Schmal, M.A., CSAC

Mental Health Therapist II

Arlington County Mental Health

Substance Abuse Services

Arlington, Virginia

Darren C. Skinner, Ph.D., LSW, CAC

Director

Gaudenzia, Inc.

Gaudenzia House West Chester

West Chester, Pennsylvania

David E. Smith, M.D.

Founder and President

Haight Ashbury Free Clinics, Inc.

San Francisco, California

Antony P. Stephen, Ph.D.

Executive Director

Mental Health and Behavioral Sciences

New Jersey Asian American Association for

Human Services, Inc.
 

Elizabeth, New Jersey
 

Norm Suchar

Program and Policy Analyst

National Alliance to End Homelessness

Washington, DC

Richard T. Suchinsky, M.D.

Associate Chief for Addictive Disorders

and Psychiatric Rehabilitation

Mental Health and Behavioral Science

Services
 

Department of Veterans Affairs
 

Washington, DC
 

Kimberly N. Sutton, Ph.D.

Director/Associate Professor of Psychiatry

Cork Institute on Alcohol and Other Drug

Abuse
 

Morehouse School of Medicine
 

Atlanta, Georgia
 

Mary Lynn Ulrey, M.S., ARNP

Chief Operating Officer

Operation PAR, Inc.

Pinellas Park, Florida

Robert Walker, M.S.W., LCSW

Assistant Professor

Center on Drug and Alcohol Research

University of Kentucky

Lexington, Kentucky

Verner Stuart Westerberg, Ph.D.

President

Addiction Services Research

Albuquerque, New Mexico

Aline G. Wommack, R.N., M.S.

Deputy Director

Division of Substance Abuse and Addiction

Medicine

UCSF Deputy Department of Psychiatry

San Francisco, California

Ann S. Yabusaki, Ph.D.

Director

Coalition for a Drug­Free Hawaii

Honolulu, Hawaii

Mariko Yamada, LCSW

Clinical Supervisor

Asian American Drug Abuse Program Inc.

Gardena, California

Debby Young

Windsor, California

Joan E. Zweben, Ph.D.

Executive Director

East Bay Community Recovery Project

University of California

Berkley, California

Field Reviewers 537
Appendix O:

Acknowledgments

Numerous people contributed to the development of this TIP, including

the TIP Consensus Panel (see page xi), the Knowledge Application

Program (KAP) Expert Panel and Federal Government Participants (see

page xiii), the Resource Panel (see Appendix L), the KAP Cultural

Competency and Diversity Network Participants (see Appendix M), and

TIP Field Reviewers (see Appendix N).

This publication was produced under KAP, a Joint Venture of The CDM

Group, Inc. (CDM), and JBS International, Inc. (JBS), under contract

number 270­047049 for the Substance Abuse and Mental Health Services

Administration, Center for Substance Abuse Treatment.

CDM KAP personnel included Executive Deputy Project Director Rose

M. Urban, M.S.W., J.D., LCSW, CCAC, CSAC; Deputy Project

Director Elizabeth Marsh; Senior Research/Applied Psychologist

Sheldon Weinberg, Ph.D.; Deputy Project Manager Raquel Witkin,

M.S.; Managing Editor Susan Kimner; Senior Editor/Writer Deborah

Steinbach; and Editorial Assistant Erica Flick. In addition, Sandra

Clunies, M.S., ICADC, served as Cont1ent Advisor. Special thanks go to

Susan Hills, Ph.D., for serving as Co­Editor on this TIP, and Doug

Ziedonis, M.D., for his contribution to Chapter 8. Jonathan Max

Gilbert, Ph.D., Margaret K. Hamer, M.P.A., Randi Henderson, B.A.,

Susan Hills, Ph.D., and David Shapiro, M.S., M.Ed., were writers.

Appendix K was prepared by Margaret Brooks, J.D., and SAMHSA

staff in consultation with the Office of the General Counsel, U.S.

Department of Health and Human Services, Washington, D.C.

539
Index

Notes: Because the entire volume is about substance abuse treatment and co­occurring disorders

(COD), the use of these terms as entry points has been minimized in this index. Tools and instruments are listed by their commonly known acronyms. Reference locators for information contained in figures appear in italics.

5 A’s for smoking cessation, 217–218, 343
 

5 Rs for smoking cessation, 339
 

12­Step groups. See mutual self­help groups
 

42 C.F.R. Part 2, 45, 75, 357, 398, 505, 523
 

A

Access to Community Care and Effective
 

Services and Supports initiative, 9
 

access to services, 41
 

acute care settings, 184
 

accessing services in, 187
 

funding streams, 190
 

screening and assessment in, 186–187
 

acute stress disorder, 372
 

Addiction and Trauma Recovery Integration
 

Model, 208
 

addiction only services, 33
 

AD/HD. See attention deficit hyperactivity
 

disorder
 

AD/HD Behavior Checklist for Adults, 407
 

adherence, in outpatient settings, 147
 

advanced assessment techniques, 78
 

advanced clinician competencies, 57, 60
 

advocacy, 54, 148
 

consumer, 196
 

for dual recovery, 194
 

agency assessment, 48, 51
 

aftercare. See continuing care
 

alcohol, as cause of disorders, 250
 

withdrawal symptoms, 250
 

alcohol myopia, 328
 

alternative classification system for 

programs, 43
 

American Academy of Addiction Psychiatry,
 

140
 

American Osteopathic Association, 140
 

American Psychiatric Publishing, Inc., 18
 

American Society of Addiction Medicine. See
 

ASAM
 

anniversary reactions, 356
 

anorexia nervosa. See eating disorders
 

antisocial personality disorder, 224–226, 350
 

antisocial thinking­error work, 368
 

assessment, 364
 

case management, 367
 

case study, 224–226
 

characteristics of, 350
 

contracting, 364, 366
 

crisis stabilization, 365
 

diagnostic features and criteria, 225, 

359–362
 

engagement, 364
 

group therapy, 366
 

prevalence data, 224
 

resistance, 363
 

rule breaking, 369
 

sanctions, 369
 

step work handout, 360–361
 

strategies for working with, 366, 367
 

terminating counseling, 367
 

anxiety disorders, 26, 226, 369, 370. See also
 

individual disorders
 

assessment, 377–378
 

caffeine­induced, 251
 

case study, 378, 379, 383, 384
 

crisis stabilization, 378–380
 

Index 541
 
diagnostic features and criteria, 230
 

diagnostic process, 372
 

differential diagnosis, 372
 

engagement, 377
 

and mutual self­help groups, 382
 

in other disorders, 372–373
 

prevalence data, 226
 

screening, 377–378
 

and substance use, 373, 375–376
 

Arapahoe House, 145, 146, 152, 154
 

ASAM (American Society of Addiction
 

Medicine), 140
 

patient placement criteria, 3, 27–28, 33,
 

42, 71, 75, 83, 84, 143
 

ASI (Addiction Severity Index), 68, 75, 80,
 

90, 163, 169, 331, 487
 

Assertive Community Treatment (ACT), 9,
 

13, 147, 152–157
 

as compared to Intensive Case 

Management, 159
 

empirical evidence for, 156
 

essential features of, 156
 

modifications for integrating COD, 155
 

recommendations for successful use, 160
 

and supportive housing, 198
 

assessment, 42, 67, 138
 

in acute care settings, 186–187
 

agency, 48, 51
 

for antisocial personality disorder, 364
 

for anxiety disorders, 377–378
 

for attention deficit/hyperactivity 

disorder, 405
 

for borderline personality disorder, 356
 

considerations, 74
 

defined, 66, 68
 

as different from screening, 68
 

dimensions of, 84
 

for eating disorders, 422–423
 

instruments, 68, 69, 78–82, 150
 

for mood and anxiety disorders, 377–378
 

needs, 48
 

for nicotine dependence, 339–343
 

in outpatient settings, 145–146
 

for pathological gambling, 430
 

person­centered, 73
 

for posttraumatic stress disorder, 415
 

process, 71
 

for psychosis, 390
 

in residential settings, 163
 

validity of, 66
 

assessment steps, 72
 

step 1, engage the client, 72–74
 

step 2, identify collaterals, 74–75
 

step 3, screen for COD, 75–82
 

step 4, determine quadrant of care, 82–84
 

step 5, determine level of care, 84–85
 

step 6, determine diagnosis, 86–89
 

step 7, determine disability, 89–91
 

step 8, identify strengths and supports,
 

91–92

step 9, identify cultural needs, 92–93

step 10, identify problem domains, 93–94

step 11, determine stage of change, 94–95

step 12, plan treatment, 95–96

Association of Problem Gambling Service
 

Administrators, 428
 

attention deficit/hyperactivity disorder,
 

235–237, 402
 

case management, 407
 

case study, 235–237
 

crisis stabilization, 406
 

diagnostic features and criteria, 236–237
 

differential diagnosis, 403
 

engagement, 404–405
 

instruments, 406–407
 

prevalence, 403–404
 

psychoeducation, 407
 

screening and assessment, 405
 

symptom clusters, 403
 

542 Index
attitudes and values, provider, 56, 57
 

audience for this TIP, 16
 

AUDIT (Alcohol Use Disorders Identification
 

Test), 81, 488
 

avoidant personality disorder, 351
 

B

BAI (Beck Anxiety Inventory), 78, 378
 

barriers, 195
 

cultural and linguistic, 93
 

to integrated care, 188
 

systemic, 47, 139
 

to treatment for women, 203
 

basic clinician competencies, 56–57, 58
 

basic program, 43
 

BDI (Beck Depression Inventory), 69, 169
 

BDI­II (Beck Depression Inventory­II), 78,
 

378, 488
 

behavioral disconnects, for smoking cessation, 345
 

benefits management, 122
 

Binge­Eating Disorder, 418
 

bipolar disorder, 26, 370, 385, 386
 

case study, 229–231, 401–402
 

cocaine­induced symptoms of, 251
 

as compared to schizophrenia, 388
 

manic episodes, 387
 

prevalence, 389
 

and schizophrenia, 390
 

and substance use, 389–390
 

block grant requirements, 48
 

borderline personality disorder, 220–224,
 

350, 353
 

and anger management, 358
 

case study, 222
 

characteristics of, 350
 

crisis stabilization, 357
 

diagnostic features and criteria, 223
 

group therapy, 357
 

engagement, 355
 

recovery rate, 355
 

screening and assessment, 356
 

and substance abuse, 354
 

Bridging the Gap Between Research and
 

Practice, 55
 

brief reactive psychosis, 386
 

BSI­18 (Brief Symptom Inventory­18), 80
 

bulimia nervosa. See eating disorders
 

burnout, staff, 62
 

C

caffeine­induced anxiety, 251
 

CAGE questionnaire, 81, 489
 

Carlisle Foundation, 53
 

case studies
 

antisocial personality disorder, 224–226
 

anxiety disorders, 378, 379, 383, 384
 

attention deficit/hyperactivity disorder, 

235–237
 

bipolar disorder, 229–231, 401–402
 

borderline personality disorder, 222
 

cognitive–behavioral therapy, 127
 

Contingency Management, 124
 

diagnosis, 86, 87
 

disability, determination of, 89, 90
 

eating disorders, 242–245
 

identifying cultural needs, 92, 93
 

level of care placement, 84
 

mood disorders, 378, 379, 383, 384
 

motivational enhancement therapy, 121
 

mutual self­help groups, 136
 

nicotine dependence, 219–220
 

pathological gambling, 247–248, 431, 433,
 

435
 

posttraumatic stress disorder, 238–240,
 

416
 

problem domains, identifying, 93
 

psychosis, 395, 396, 400, 401
 

quadrants of care, 83
 

Relapse Prevention Therapy, 134
 

Index 543
 
repetition, 135
 

schizophrenia, 233–235
 

stages of change, 94
 

strengths and supports, identifying, 91
 

suicidality, 216
 

treatment planning, 69, 70
 

Catalog of Federal Domestic Assistance, 52
 

Center for Mental Health Services Managed
 

Care Initiative Panel, 38
 

centralized intake, 146
 

certification, 63
 

limitations of authority, 66
 

challenges in working with clients with COD,
 

103–104
 

Change Book: A Blueprint for Technology
 

Transfer, The, 152
 

“change talk,” 114–115
 

Changing the Conversation, 11, 55
 

Chevron Foundation, 53
 

child care, 203
 

CINA (Clinical Institute Narcotic
 

Assessment), 76
 

CIWA­Ar (Clinical Institute Withdrawal
 

Assessment), 76, 490
 

Clackamas County 

Mental Health Center, 145, 152, 153
 

program for persons in jails, 202
 

classification system, alternative, 43
 

client 

empowerment, 105
 

engagement, 39, 72
 

history, 86–88
 

role of, 126
 

Client Behavior Checklist, 405
 

Clinical Practice Guidelines on Treating
 

Tobacco Use and Dependence, U.S. Public
 

Health Service, 218
 

Clinical Trials Network, NIDA, 80, 112
 

clinician 

comfort level with client, 102–103
 

competencies, 56–57
 

role of, 126
 

clusters, DSM­IV, 24, 349–351
 

CMR scales (Circumstances, Motivation, and
 

Readiness), 105, 489
 

cocaine, as cause of disorders, 251
 

COD 

certification, 62
 

defined, 3, 26–27
 

terminology, 3
 

coercion, therapeutic, 394
 

cognitive–behavioral therapy, 125–127, 377,
 

433
 

case study, 127
 

cognitive impairments, 40, 133
 

collaboration
 

between recovery movements, 196
 

between substance abuse and mental 

health agencies, 145
 

defined, 45
 

collaterals, 67, 74–75, 365, 392, 431
 

Colorado Prison program, 203
 

Community Action Grants, 13
 

community building, 40
 

Community Connections, 209
 

community reintegration, 41
 

competencies
 

basic, 56–57, 58
 

integrated, 32
 

intermediate, 57, 59
 

Comprehensive Continuous Integrated
 

System of Care model, 35, 38
 

comprehensive services, 46
 

comprehensive system of care, 50
 

confidentiality, 45, 75, 357, 398, 505, 523
 

confrontation, 109–110, 169, 365
 

confused bias, 191
 

Conners Abbreviated Symptom
 

Questionnaire, 405
 

Conners Continuous Performance Test, 406
 

544 Index
consensus guidelines, State, 58
 

consultation, 138
 

defined, 45
 

psychopharmacologic, 149
 

Consumer Advisory Group, 143
 

Consumer Organization and Networking
 

Technical Assistance Center (CONTAC),
 

196
 

Contingency Management, 121–125
 

case study, 124
 

checklist for designing programs, 123
 

empirical evidence, 122
 

continuing care, 148, 164, 189
 

continuing education, 59
 

continuity of care, 47, 106
 

Continuous Quality Improvement plan, 170
 

continuous support, 105–106
 

Co­Occurring Center for Excellence, 14–15,
 

168
 

Co­Occurring Collaborative of Southern
 

Maine, 48, 49
 

Co­Occurring Disorders: Integrated Dual
 

Disorders Treatment Implementation
 

Resource Kit, 16
 

Co­Occurring Disorders State Incentive
 

Grants, 14
 

coping strategies, 133
 

Core Center, The, 186
 

Corrections Substance Abuse Program, 202
 

counselor 

integrated competencies, 32
 

reliability, 355
 

role, 13
 

well­being, 363
 

countertransference, 106–107, 363, 429
 

Criminal Justice Drug Abuse Treatment
 

System (NIDA), 201
 

criminal justice populations, 9, 200, 362
 

empirical evidence, 203
 

prevalence, 200–201
 

treatment features, 201
 

crisis intervention, 155
 

crisis stabilization, 331
 

antisocial personality disorder, 365
 

anxiety disorders, 378–380
 

attention deficit/hyperactivity disorder, 

406
 

bipolar disorder, 357
 

eating disorders, 423
 

mood disorders, 378–380
 

pathological gambling, 431
 

posttraumatic stress disorder, 415
 

psychosis, 394
 

suicidality, 331
 

criteria
 

for serious mental illness diagnosis, 83
 

for substance abuse diagnosis, 22
 

treatment, 10
 

cross­cutting issues, 214–215
 

cross­training, 60, 149, 188
 

culture, 107
 

barriers, 93
 

case study, 92, 93
 

empirical evidence
 

and family education, 143
 

identifying needs, 92–93
 

and perceptions of substance abuse, 110
 

cultural competence
 

continuum, 31
 

defined, 31
 

sensitivity, 73
 

cyclothymic disorder, 370
 

D

DALI (Dartmouth Assessment of Lifestyle
 

Inventory), 81
 

DAST (Drug Abuse Screening Test), 81, 490
 

data 

analysis plan, 151
 

collection, 150
 

Index 545
 
decisional balance, 115
 

definitions 

assessment, 66, 68
 

COD, 3
 

collaboration, 45
 

consultation, 45
 

cultural competence, 31
 

integration, 45
 

mental health service system, 34
 

program, 32
 

recovery, 104
 

screening, 66
 

substance abuse, 22
 

substance abuse treatment system, 34
 

substance dependence, 22
 

system, 33
 

deinstitutionalization, 144
 

delirium, alcohol­induced, 250
 

demographics, 54
 

Demystifying Evaluation: A Manual for
 

Evaluating Your Substance Abuse
 

Treatment Program, 151
 

dental care, 393
 

dependent personality disorder, 351
 

depression, 25–26. See also major depression
 

nicotine­induced, 252
 

and suicidality, 214
 

diagnosis, 86–89
 

case studies, 86, 87
 

and cultural and ethnic bias, 111
 

documentation of, 88, 325
 

of substance­induced mental disorders, 

252–253
 

diagnostic features and criteria
 

antisocial personality disorder, 225, 

359–362
 

anxiety disorders, 230
 

attention deficit/hyperactivity disorder, 

236–237
 

borderline personality disorder, 223
 

eating disorders, 243–244
 

mood disorders, 227
 

nicotine dependence, 333–334
 

nicotine withdrawal, criteria for, 341
 

pathological gambling, 247, 426
 

personality disorders, 221
 

posttraumatic stress disorder, 239–240
 

schizophrenia, 232–233
 

substance abuse, 22
 

substance dependence, 23
 

Dialectical Behavior Therapy, 242, 358
 

dimensions of assessment, 84
 

DIS (Diagnostic Interview Schedule), 78
 

disability, determination of, 89–91
 

case studies, 89, 90
 

discharge planning, 147–148, 164
 

discrepancy, developing, 113
 

District of Columbia Trauma Collaboration
 

Study, 209
 

documenting prior diagnoses, 88, 325
 

for psychosis, 392
 

for suicidality, 331
 

Double Trouble groups, onsite, 141
 

empirical evidence for, 193–194
 

types of meetings, 192
 

Double Trouble in Recovery, 192
 

Drexel University, 4
 

Drug Abuse Treatment Outcome Study
 

(DATOS), 7, 109, 144, 161, 351
 

DSM­IV, 86
 

clusters, 24
 

Dual Diagnosis Anonymous, 192
 

dual diagnosis 

capable programs, 33, 85
 

conferences, 4
 

enhanced programs, 33, 85
 

Dual Diagnosis Recovery Network, 195
 

Dual Disorders Anonymous, 192
 

Dual Recovery Empowerment Foundation,
 

195
 

546 Index
dual recovery mutual self­help groups, offsite, 141, 190–191
 

dysthymia, 370
 

E

eating disorders, 240–246, 417
 

case study, 242–245
 

clinical features, 420
 

and comorbidity, 419
 

crisis stabilization, 423
 

diagnostic features and criteria, 243–244
 

engagement, 422
 

pharmacological agents, abuse of, 421
 

prevalence, 241, 418
 

relapse prevention, 424, 425
 

screening and assessment, 422–423
 

and substance abuse, 418, 419–420, 421
 

treatment completion, 423
 

Eating Disorders Examination, 422
 

education and training, 58
 

substance abuse, in medical schools, 140
 

efficiency, 53
 

empathic detachment, 73
 

empathy, 109, 113
 

employment, and contingency management,
 

122
 

empowerment, client, 105
 

engagement, 39, 72, 147, 163–164
 

clients with antisocial personality disorder,
 

364
 

clients with anxiety disorders, 377
 

clients with attention deficit/hyperactivity 

disorder, 404–405
 

clients with borderline personality 

disorder, 355
 

clients with eating disorders, 422
 

clients with mood and anxiety disorders, 

377
 

clients with nicotine dependence, 339–343
 

clients with pathological gambling, 429
 

clients with psychosis, 390, 391
 

clients with suicidality, 329
 

interventions, 164, 165
 

Epidemiologic Catchment Area study, 6, 389
 

Epidemiologic Catchment Area Survey of
 

Mental Disorders, 9
 

Expenditures on Treatment of Co­Occurring
 

Mental and Substance Use Disorders, 54
 

F

Fagerstrom Test for Nicotine Dependence,
 

335, 340, 342
 

family 

education, 143
 

history, 328
 

role in modified therapeutic community, 

173
 

support, 41, 347, 357, 398
 

Feeling Good Handbook, The, 379
 

financing, 50, 52
 

Foundation Center, 53
 

Foundations Associates, 181–182 

foundation matching funds, 53
 

free time, strategies for managing, 112
 

functional impairments, 40
 

funding, 50, 52, 53, 145, 151
 

G

GAI (Gambler Assessment Index), 429
 

GAIN (Global Appraisal of Individual Needs),
 

75, 85, 90, 169, 491
 

gambling. See pathological gambling
 

Gambling Severity Index, 430
 

GAMTOMS (Gambling Treatment Outcome
 

Monitoring System), 430
 

gaps, system, 50
 

Gaudenzia, Inc., 175, 176
 

GDS (Gordon Diagnostic System), 406
 

generalized anxiety disorder, 370
 

Grants for Evaluation of Outpatient
 

Treatment Models for Persons With CoOccurring Substance Abuse and Mental
 

Health Disorders, 152
 

Index 547
 
Greenhouse Program, 199–200
 

grounding, 126, 240, 412, 413–414
 

group therapy 

for clients with antisocial personality dis
 

order, 366
 

for clients with borderline personality dis
 

order, 357
 

for clients with psychosis, 395
 

modified for clients with COD, 142
 

GTAQ (Gambling Treatment Admission
 

Questionnaire), 430
 

guiding principles for programs, 38
 

H

hallucinogens, as cause of disorders, 251
 

hallucinosis, 87
 

Hamilton Anxiety Scale, 78
 

Hamilton Rating Scale for Depression, 78
 

Harborview Medical Center Crisis Triage
 

Unit, 185
 

harm. See self­harm
 

Healing the Trauma of Abuse, 209
 

Health Insurance Portability and
 

Accountability Act (HIPAA), 523
 

Helping Women Recover: A Program for
 

Treating Addiction, 208
 

history
 

client, 86–88
 

COD study, 2
 

histrionic personality disorder, 350
 

HIV/AIDS, 9, 145
 

HIV Integration Project, 186
 

holistic treatment, 187
 

homeless population, 8–9, 46, 145
 

and COD, 197–200

hospitalization rates, 7–8

housing, 46, 197–200

and contingency management, 122
 

contingent on treatment, 199
 

integrated with treatment, 199–200
 

stability, 198
 

How Good Is Your Drug Abuse Treatment
 

Program? A Guide to Evaluation, 151
 

Hyperkinesis­Minimal Brain Dysfunction
 

Childhood Symptom Checklist, 405
 

I
 

identifying cultural needs, 92–93
 

case studies, 92, 93
 

Individualized Placement and Support
 

model, 92
 

individual therapy
 

for antisocial personality disorder, 366
 

for borderline personality disorder, 358
 

infectious disease, 9
 

instruments
 

AD/HD Behavior Checklist for Adults, 407
 

ASI (Addiction Severity Index), 68, 75, 80,
 

90, 163, 169, 331, 487
 

AUDIT (Alcohol Use Disorders 

Identification Test), 81, 488
 

BAI (Beck Anxiety Inventory), 78, 378
 

BDI (Beck Depression Inventory), 69, 169
 

BDI­II (Beck Depression Inventory­II), 

78, 378, 488
 

BSI­18 (Brief Symptom Inventory­18), 80
 

CAGE questionnaire, 81, 489
 

CINA (Clinical Institute Narcotic 

Assessment), 76
 

CIWA­Ar (Clinical Institute Withdrawal 

Assessment), 76, 490
 

Client Behavior Checklist, 405
 

CMR scales (Circumstances, Motivation, 

and Readiness), 105, 489
 

Conners Abbreviated Symptom 

Questionnaire, 405
 

Conners Continuous Performance Test, 

406
 

DALI (Dartmouth Assessment of Lifestyle 

Inventory), 81
 

DAST (Drug Abuse Screening Test), 81, 

490
 

DIS (Diagnostic Interview Schedule), 78
 

548 Index
Eating Disorders Examination, 422

Fagerstrom Test for Nicotine Dependence, 

335, 340, 342
 

GAI (Gambler Assessment Index), 429
 

GAIN (Global Appraisal of Individual 

Needs), 75, 85, 90, 169, 491
 

Gambling Severity Index, 430
 

GAMTOMS (Gambling Treatment 

Outcome Monitoring System), 430
 

GDS (Gordon Diagnostic System), 406
 

GTAQ (Gambling Treatment Admission 

Questionnaire), 430
 

Hamilton Anxiety Scale, 78
 

Hamilton Rating Scale for Depression, 78
 

Hyperkinesis­Minimal Brain Dysfunction 

Childhood Symptom Checklist, 405
 

Lie/Bet Questionnaire, 429
 

LOCI­2R, 85
 

LOCUS (Level of Care Utilization System
 

for Psychiatric and Addiction
 

Services), 28, 75, 83, 85, 491–492
 

MASST, 380
 

MAST (Michigan Alcohol Screen Test), 81,
 

492
 

MCMI (Millon Clinical Multiaxial 

Inventory), 365
 

Mental Health Screening Form­III, 67, 68
 

MHSF­III (Mental Health Screening 

Form­III), 79, 498, 500–501
 

M.I.N.I. (Mini­International 

Neuropsychiatric Interview), 79, 89
 

M.I.N.I. Plus, 492
 

MMPI­2 (Minnesota Multiphasic 

Personality Inventory­2), 78, 365
 

Modified PTSD Symptom Scale, 415
 

Self­Report Version, 82
 

PCL­R (Hare Psychopathy ChecklistRevised), 365
 

PRISM (Psychiatric Research Interview
 

for Substance and Mental Disorders),
 

78, 493
 

PTSD Checklist, 82
 

RAATE (Recovery Attitude and Treatment
 

Evaluator), 494
 

Readiness to Change Questionnaire, 493
 

SATS (Substance Abuse Treatment Scale), 

95, 495
 

SCID (Structured Clinical Interview for 

Diagnosis), 78
 

SCID­IV, 494
 

SDS (Symptom Distress Scale), 68
 

SEEQ (Scale of Essential Elements 

Questionnaire), 170
 

SOCRATES (Stages of Change Readiness 

and Treatment Eagerness Scale), 94
 

SOGS (South Oaks Gambling Screen), 429
 

SSI­SA (Simple Screening Instrument for 

Substance Abuse), 81, 499, 502–512
 

Timeline Follow Back Method, 89
 

TOVA (Test of Variables of Attention), 406
 

URICA (University of Rhode Island 

Change Assessment Scale), 68, 94, 495
 

Victorian Problem Gambling Family 

Impact Scale, 431
 

Wender Utah Rating Scale, 405
 

intake, 162
 

centralized, 146
 

information, 68
 

interview, 162
 

integrated care framework, 10
 

integrated competencies, counselor, 32
 

Integrated Data Base Project, 8
 

integrated interventions, 29
 

Integrated Trauma Services Teams, 209
 

integrated treatment, 11, 30–31, 43, 44,
 

69–71, 130–132, 138
 

barriers to, 188
 

for borderline personality disorder, 357
 

financing in outpatient settings, 151
 

and posttraumatic stress disorder, 412
 

integration
 

defined, 45
 

of housing and treatment, 199
 

Index 549
 
of substance abuse treatment and primary 

care, 184
 

Intensive Case Management (ICM), 9, 13,
 

147, 157–158
 

as compared to Assertive Community 

Treatment, 159
 

empirical evidence for, 158–159
 

interventions, 158
 

modifications for COD, 158
 

recommendations for successful use, 160
 

Intensive Outpatient Program criteria
 

(ASAM), 143
 

intermediate clinician competencies, 57, 59
 

intermediate program, 43
 

International Society for Traumatic Stress
 

Studies, 412
 

intersystem linkages, 34–35
 

intervention, 29, 39, 104–105, 171
 

engagement, 164, 165
 

to enhance readiness to change, 118
 

intensive case management, 158
 

motivation­based, 119
 

psychoeducational group, 194
 

Ittleson Foundation, Inc., 53
 

K

knowledge exchange, 55
 

L

legal problems, and pathological gambling,
 

428, 432
 

level of care placement, 42, 84–85, 146
 

case study, 84
 

Lie/Bet Questionnaire, 429
 

linguistic needs, identifying, 92–93
 

linkages, 148, 158, 188, 193
 

of institutional services to community 

services, 201
 

intersystem, 34–35
 

LOCI­2R, 85
 

LOCUS (Level of Care Utilization System for
 

Psychiatric and Addiction Services), 28,
 

75, 83, 85, 491–492
 

licensure limitations, 66
 

listservs, 62
 

M

major depression, 206, 226, 370
 

features and criteria, 227
 

manic­depressive illness. See bipolar disorder
 

manic episode, 26, 387
 

features and criteria, 228–229
 

Mary Owen Border Foundation, 53
 

MASST, 380
 

MAST (Michigan Alcohol Screen Test), 81,
 

492
 

MCMI (Millon Clinical Multiaxial Inventory),
 

365
 

medical settings, 184
 

accessing services in, 187
 

funding streams, 190
 

screening and assessment in, 186–187
 

medication, 13
 

adherence to, 129, 390, 393, 399
 

continuity of management, 148
 

monitoring, 107, 108, 140, 155
 

for smoking cessation, 335
 

memorandum of agreement, 139, 145
 

mental disorders 

and nicotine dependence, 336
 

psychoeducational classes on, 140
 

screening for, 76–79
 

symptoms mimicked by substances, 78–79
 

terminology, 24
 

mental health program, 32
 

Mental Health Screening Form­III, 67, 68
 

mental health service system, defined, 34
 

MHSF­III (Mental Health Screening FormIII), 79, 498, 500–501
 

M.I.N.I. (Mini­International
 

Neuropsychiatric Interview), 79, 89
 

M.I.N.I. Plus, 492
 

MMPI­2 (Minnesota Multiphasic Personality
 

Inventory­2), 78, 365
 

550 Index
models

Addiction and Trauma Recovery 

Integration Model, 208
 

Arapahoe House, 145, 146, 152, 154
 

Assertive Community Treatment (ACT), 9,
 

13, 147, 152–157
 

as compared to Intensive Case 

Management, 159
 

empirical evidence for, 156
 

essential features of, 156
 

modifications for integrating COD, 155
 

recommendations for successful
 

use, 160
 

and supportive housing, 198
 

Clackamas County Mental Health Center, 

145, 152, 153
 

Community Connections, 209
 

Comprehensive Continuous Integrated 

System of Care model, 35, 38
 

Foundations Associates, 181–182 

Gaudenzia, Inc., 175, 176
 

Harborview Medical Center Crisis Triage 

Unit, 185
 

HIV Integration Project, 186
 

Individualized Placement and Support 

model, 92
 

Intensive Case Management (ICM), 9, 13, 

147, 157–158
 

as compared to Assertive Community 

Treatment, 159
 

empirical evidence for, 158–159
 

interventions, 158
 

modifications for COD, 158
 

recommendations for successful 

use, 160
 

Na’nizhoozi Center, Inc., 180
 

Support Together for Emotional/Mental 

Serenity and Sobriety (STEMSS), 194
 

TARGET (Trauma Adaptive Recovery 

Group Education and Therapy), 

208, 411
 

Trauma Recovery and Empowerment 

Model (TREM), 208
 

TREM groups, 209
 

Triad Women’s Project, 211
 

Modified PTSD Symptom Scale, 415
 

Self­Report Version, 82
 

Modified Therapeutic Community (MTC), 13,
 

171, 173, 178, 200
 

monitoring, 155
 

mood disorders, 25, 226, 369. See also individual disorders
 

assessment, 377–378
 

case study, 375, 378, 379, 383, 384
 

crisis stabilization, 378–380
 

diagnostic features, 227
 

drugs that precipitate, 373
 

engagement, 377
 

and mutual self­help programs, 382
 

prevalence, 374–375
 

screening, 377–378
 

and stimulant withdrawal, 374
 

and substance abuse, 375–376
 

mood episode, 369
 

motivational enhancement therapy, 113,
 

117–118
 

case study, 121
 

Motivational Enhancement Therapy Manual,
 

113
 

Motivational Interviewing, 112–121
 

adapted for people with COD, 116–119
 

guiding principles, 114
 

mutual self­help groups, 12, 13–14, 40, 133,
 

135–136
 

for borderline personality disorder, 359
 

case study, 136
 

dual recovery, offsite, 141, 190–191
 

for mood and anxiety disorders, 382
 

in outpatient settings, 148–149
 

for pathological gambling, 434–435
 

Index 551
 
N

Na’nizhoozi Center, Inc., 180
 

narcissistic personality disorder, 350
 

National Association of State Alcohol and
 

Drug Abuse Directors, 3, 45, 50
 

National Association of State Mental Health
 

Program Directors, 3, 45, 50
 

National Comorbidity Study, 5–6, 374
 

National Comorbidity Survey Replication, 6
 

National Council on Alcoholism and Drug
 

Dependence, 195
 

National Council on Problem Gambling, 428
 

National Dialogue on Co­Occurring Mental
 

Health and Substance Abuse Disorders, 28
 

National Empowerment Center, 196
 

National Longitudinal Alcohol Epidemiologic
 

Study, 6
 

National Mental Health Association, 195
 

National Registry of Effective Programs and
 

Practices (NREPP), 14, 178
 

National Survey of Substance Abuse
 

Treatment Services (N­SSATS), 7, 10
 

National Survey on Drug Use and Health
 

(NSDUH), 4–5, 204
 

National Treatment Improvement Evaluation
 

Study (NTIES), 2
 

needs assessment, 48
 

network therapy, 367
 

new treatment models, 3
 

nicotine dependence, 216–220, 333–334
 

and addiction recovery, 337
 

case study, 219–220
 

craving, 338
 

and depression, 252
 

diagnostic criteria, 333–334
 

differential diagnosis, 334–335
 

effect of abstinence on medication, 337
 

engagement, 339–343
 

and mental disorders, 336
 

motivational interventions, 339
 

motivation to quit, 338
 

prevalence, 216–217, 335
 

psychosocial treatment, 346–347
 

relapse, 339
 

screening and assessment, 339–343
 

strategies for quitting, 344
 

and symptoms of depression, 252
 

timing of quit attempt, 336
 

treating, 343–347
 

withdrawal, 341
 

nicotine replacement therapy, 334, 346
 

“no wrong door,” 11, 72, 184
 

nutrition, and clients with COD, 393
 

O

obsessive­compulsive disorder, 371
 

obsessive­compulsive personality disorder,
 

351
 

Odyssey House, 175
 

offender populations, 9
 

on­the­job training, 149
 

opioids, as cause of disorders, 252
 

organizational change, planning for, 152
 

orientation, 61
 

outpatient treatment for clients with COD,
 

143–144
 

and continuing care, 148
 

and discharge planning, 147–148
 

empirical evidence, 144
 

and engagement, 147
 

evaluation process, 150
 

funding resources, 151
 

implementing, 149–150
 

prevalence, 144
 

referral and placement for, 146
 

staffing for, 149
 

training for, 149–150
 

P

panic attack, 371
 

panic disorder, 371
 

paranoid personality disorder, 349
 

552 Index
parasitic relationships, 365
 

parasuicide, 326
 

pathological gambling, 246–248, 425
 

assessment, 430
 

case study, 247–248, 431, 433, 435
 

cognitive–behavioral treatment for, 433
 

and collaterals, 431
 

crisis stabilization, 431
 

diagnostic features and criteria, 247, 426
 

and domestic violence, 432
 

engagement, 429
 

legal problems associated with, 428, 432
 

mutual self­help groups, 434–435
 

prevalence data, 246, 427–428
 

psychodynamic therapies, 432
 

self­banning, 432
 

and substance use, 430
 

suicidality, 431
 

training and supervision, 428
 

transference and countertransference, 429
 

triggers, 434
 

types of, 425, 427
 

Pathways to Housing, 198
 

patient placement, 146
 

criteria, 3, 27–28, 33, 42, 71, 75, 83, 84, 

143
 

Pavillon International, 63
 

PCL­R (Hare Psychopathy ChecklistRevised), 365
 

peer networks, positive, 148
 

Performance Partnership Grants, 14
 

personality disorders, 24, 220, 348–349
 

diagnostic features and criteria, 221
 

differential diagnosis, 351
 

prevalence, 351–353
 

and substance abuse, 353
 

Personal Reflections, modified TC, 203
 

person­centered 

assessment, 73
 

terminology, 26
 

Person With Mental Illness and Substance
 

Abuse, The (conference), 4
 

phases of treatment, 39
 

phobia, 371
 

Phoenix House, 175
 

“ping­pong” phenomenon, and eating disorders, 423, 425
 

postpartum depression, 206–207
 

posttraumatic stress disorder, 10, 82,
 

238–240, 372
 

case study, 238–240, 416
 

crisis stabilization, 415
 

descriptive features, 408
 

diagnostic features and criteria, 239–240
 

and grounding, 126, 412, 413–414
 

and integrated treatment, 412
 

prevalence, 409
 

psychoeducation, 415
 

screening and assessment, 415
 

and substance abuse, 409, 415
 

trauma exploration work, 416
 

treatment models, 411
 

treatment outcomes, 412
 

trust, establishing, 411
 

Practice Improvement Collaboratives, 55
 

pregnancy, 205
 

prescribing guidelines, 140
 

prevalence data, 4–8
 

antisocial personality disorder, 224
 

anxiety disorders, 226
 

attention deficit/hyperactivity disorder, 

403–404
 

bipolar disorder, 389
 

criminal justice populations, 200–201
 

eating disorders, 241, 418
 

mood disorders, 374–375
 

nicotine dependence, 216–217, 335
 

outpatient treatment for clients with COD,
 

144
 

Index 553
 
pathological gambling, 246, 427–428
 

personality disorders, 351–353
 

posttraumatic stress disorder, 409
 

residential treatment programs for clients 

with COD, 161
 

schizophrenia, 389
 

suicidality, 215, 326–327
 

PRISM (Psychiatric Research Interview for
 

Substance and Mental Disorders), 78, 493
 

private funding opportunities, 53
 

problem domains, identifying, 93–94
 

case study, 93
 

professional development, continuing, 57. See
 

also workforce development
 

program
 

basic, 43
 

changes for addressing nicotine dependence, 218
 

defined, 32
 

design for outpatient, 144–149
 

guiding principles for, 38
 

evaluation, 189
 

intermediate, 43
 

review, 162
 

Project Return Foundation, Inc., 79, 498
 

protocol, screening, 66
 

psychiatric symptoms, monitoring, 107–109
 

instruments for, 108
 

psychiatrist, prescribing onsite, 139–140
 

psychoeducation, 140–141, 203, 332, 407, 415
 

psychoeducational group intervention, 194
 

psychopharmacology, 149, 343, 381, 434
 

psychosis, 87, 385
 

and assertive case management, 397
 

and behavioral and psychoeducational 

perspective, 397
 

case studies, 395, 396, 400, 401
 

and collateral resources, 392
 

crisis stabilization, 394
 

differential diagnosis, 387–388
 

documentation, 392
 

engagement, 390, 391
 

and group treatment, 395
 

and high­risk conditions, 391, 394
 

laboratory testing, 392
 

medical risks, 391
 

psychosocial needs, 397
 

and reactions to medication, 388
 

relapse prevention, 398
 

screening and assessment, 390
 

and social supports, 391
 

subacute conditions, 395
 

and suicidality, 390
 

versus substance­induced psychotic 

disorder, 387–388
 

treatment teams, 397
 

vocational services, 398
 

psychotic disorders, 24–25
 

PTSD. See posttraumatic stress disorder
 

PTSD Checklist, 82
 

purpose of this TIP, 1
 

Q

QPR Institute for Suicide Prevention, 329
 

quadrants of care, 28–29, 30, 45, 82, 185
 

assignment to, 82
 

case study, 83
 

quit attempt, timing of smoking, 336, 345
 

R

RAATE (Recovery Attitude and Treatment
 

Evaluator), 494
 

Readiness to Change Questionnaire, 493
 

reassessment, 146
 

recovery, defined, 104
 

recovery perspective, 38, 104–106
 

referral, 138, 146, 162
 

relapse prevention, 339, 345, 347, 348, 398,
 

424, 425
 

education, 133, 141
 

Relapse Prevention Therapy, 128–133
 

554 Index
case study, 134
 

empirical evidence, 129
 

strategies for clients with COD, 133
 

repetition, 133
 

case study, 135
 

Report to Congress on the Prevention and
 

Treatment of Co­Occurring Substance Use
 

Disorders and Mental Disorders, 15
 

representative payeeships, 122, 155, 198, 394
 

residential treatment programs for clients
 

with COD, 161
 

and assessment, 163
 

client engagement in, 163–164
 

designing for clients with COD, 162
 

discharge planning, 164
 

empirical evidence for, 161
 

evaluating, 169
 

intake procedures, 162
 

interventions, 172–173
 

prevalence, 161
 

retention threshold, 162
 

staffing, 164
 

resistance, 113–114, 363
 

resource allocation, 53
 

retesting, 79
 

risk 

assessment, for suicidality, 329, 330–331
 

of harm, 77
 

role 

client, 126
 

counselor, 13, 126
 

role­playing, 133
 

Ryan White Care Act, 190
 

S

safety screen, 75
 

Salvation Army shelter, 199–200
 

SATS (Substance Abuse Treatment Scale), 95,
 

495
 

schizoid personality disorder, 349
 

schizophrenia, 25, 231–235, 385–386
 

case study, 233–235
 

as compared to bipolar disorder, 388
 

descriptive features and criteria, 232–233
 

prevalence, 389
 

and substance use, 389–390
 

and suicidality, 390
 

types of, 386
 

schizotypal personality disorder, 349–350
 

SCID (Structured Clinical Interview for
 

Diagnosis), 78
 

SCID­IV, 494
 

scope of this TIP, 16
 

screening, 138
 

in acute care settings, 186–187
 

for antisocial personality disorder, 364
 

for anxiety disorders, 377–378
 

for attention deficit/hyperactivity 

disorder, 405
 

for borderline personality disorder, 356
 

defined, 66
 

as different from assessment, 68
 

for eating disorders, 422–423
 

instruments, 78–82
 

for mental disorders, 76–79
 

for mood and anxiety disorders, 377–378
 

for nicotine dependence, 339–343
 

for posttraumatic stress disorder, 415
 

protocol, 66
 

for psychosis, 390
 

for safety risk, 75
 

for suicidality, 329
 

toxicology, 81
 

trauma, 82
 

SDS (Symptom Distress Scale), 68
 

Second Genesis, 175
 

secure settings, 146
 

sedatives, as cause of disorders, 252
 

Seeking Safety, 208, 411
 

Index 555
 
SEEQ (Scale of Essential Elements
 

Questionnaire), 170
 

self­efficacy, 114
 

self­harm, 76, 108, 326, 356
 

self­medication, 376
 

serious mental illness (SMI) status, 83
 

services, comprehensive, 46
 

severity checklists, 81
 

severity of disorders, 83
 

sexual orientation, 73
 

Single State Agencies, 33
 

smoking. See nicotine dependence
 

Social Security Disability Insurance, 92
 

SOCRATES (Stages of Change Readiness and
 

Treatment Eagerness Scale), 94
 

SOGS (South Oaks Gambling Screen), 429
 

special populations, 145, 197
 

SSI­SA (Simple Screening Instrument for
 

Substance Abuse), 81, 499, 502–512
 

staff
 

burnout, 62
 

development, 139, 149
 

outpatient treatment, 149
 

in residential settings, 164
 

support, 55
 

turnover, 63, 64
 

stages of change, 94–95, 105, 112, 115, 116
 

case study, 94
 

in nicotine dependence, 339
 

standards of practice, 56
 

State Alcohol and Drug Abuse Profile, 6–7
 

State consensus guidelines, 58
 

State funding opportunities, 52
 

stigma, 3, 40, 191, 361
 

strengths and supports, identifying, 91–92
 

case studies, 91
 

structure, 112
 

substance abuse
 

and client perception of, 110
 

criteria for diagnosis, 22
 

defined, 22
 

education and training in medical schools, 

140
 

treatment program, 33
 

substance abuse treatment system, defined,
 

34
 

substance dependence
 

criteria for diagnosis, 23
 

defined, 22
 

substance­induced symptoms, 68, 108,
 

249–250
 

case studies, 253–254
 

criteria for, 253
 

diagnosis of, 252–253
 

suicidality, 27, 76, 79, 108–109, 214–216, 326
 

and bipolar disorder, 390
 

case study, 216
 

and chronic medical illness, 327
 

contracts, 329, 431
 

crisis stabilization, 331
 

depression, 214
 

differential diagnosis, 326
 

documentation, 331
 

engagement, 329
 

and pathological gambling, 431
 

prevention of, 328
 

prevalence, 215, 326–327
 

psychoeducation, 332
 

risk assessment, 329, 330–331
 

risk factors, 327, 328
 

and schizophrenia, 390
 

screening for, 329
 

and youth, 215
 

supervision, 61
 

Supplemental Security Income, 92
 

support, continuous, 105–106
 

supportive housing, 198–199
 

support systems, 40, 112
 

556 Index
Support Together for Emotional/Mental
 

Serenity and Sobriety (STEMSS), 194
 

Surgeon General Report on the Health
 

Consequences of Smoking, 216–217
 

symptom checklists, 81
 

Symptom Checklist­90, 169
 

system
 

barriers, 47, 139
 

defined, 33
 

gaps, 50
 

T

TARGET (Trauma Adaptive Recovery Group
 

Education and Therapy), 208, 411
 

team 

building, 188
 

meeting, 163
 

technical assistance, 168
 

techniques for working with clients with
 

COD, 112
 

“teeter totter” principle, 108, 250
 

terminology
 

COD, 3, 26–27
 

mental disorders, 24
 

person­centered, 26
 

therapeutic alliance, guidelines for, 102
 

therapeutic communities, 170–175
 

current applications, 175
 

empirical evidence for, 175
 

modifications for COD, 174
 

Therapeutic Community: Theory, Model, and
 

Method, The, 171
 

therapeutic environment, 170
 

Timeline Follow Back Method, 89
 

TIPs cited
 

Alcohol and Other Drug Screening of
 

Hospitalized Trauma Patients 

(TIP 16), 184
 

Assessment and Treatment of Patients
 

With Coexisting Mental Illness and
 

Alcohol and Other Drug Abuse
 

(TIP 9), 1
 

Brief Interventions and Brief Therapies
 

for Substance Abuse (TIP 34), 125, 184
 

Combining Alcohol and Other Drug Abuse
 

Treatment With Diversion for
 

Juveniles in the Justice System (TIP
 

21), 197
 

Comprehensive Case Management for
 

Substance Abuse Treatment (TIP 27),
 

157
 

Continuity of Offender Treatment for
 

Substance Use Disorders From
 

Institution to Community (TIP 30), 197
 

Detoxification From Alcohol and Other
 

Drugs (TIP 19), 184
 

Enhancing Motivation for Change in
 

Substance Abuse Treatment (TIP 35),
 

39, 95, 105, 109
 

Guide to Substance Abuse Services for
 

Primary Care Clinicians, A (TIP 24),
 

184
 

Improving Cultural Competence in
 

Substance Abuse Treatment (in development), 31, 66, 73, 110
 

Integrating Substance Abuse Treatment
 

and Vocational Services (TIP 38), 46
 

Planning for Alcohol and Other Drug
 

Abuse Treatment for Adults in the
 

Criminal Justice System (TIP 17), 197
 

Simple Screening Instruments for
 

Outreach for Alcohol and Other Drug
 

Abuse and Infectious Diseases
 

(TIP 11), 81
 

Substance Abuse Among Older Adults
 

(TIP 26), 375
 

Substance Abuse Treatment: Addressing
 

the Specific Needs of Women (in development), 73, 197, 204, 208
 

Substance Abuse Treatment and Domestic
 

Violence (TIP 25), 411
 

Substance Abuse Treatment and Trauma
 

(in development), 10, 74, 208, 408,
 

411, 416
 

Substance Abuse Treatment for Adults in
 

the Criminal Justice System (in development), 197, 362
 

Index 557
 
Substance Abuse Treatment for Persons
 

With Child Abuse and Neglect Issues
 

(TIP 36), 62, 82, 355
 

Substance Abuse Treatment for Persons
 

With HIV/AIDS (TIP 37), 184
 

Substance Abuse Treatment: Group
 

Therapy (TIP 41), 142
 

Substance Use Disorder Treatment for
 

People With Physical and Cognitive
 

Disabilities (TIP 29), 146, 403
 

tobacco, steps for addressing, 219. See also
 

nicotine dependence
 

token economy, 122
 

tool kit, 16
 

tools. See instruments
 

TOVA (Test of Variables of Attention), 406
 

toxicology screening, 81
 

training, 56, 166–168, 428
 

for pathological gambling, 428
 

resources, 61
 

staff, 149–150
 

types, 189
 

transference, 106, 363, 429
 

trauma, 10, 74, 416
 

models for recovery, 207–208
 

screening for, 82
 

and women, 205
 

Trauma Recovery and Empowerment Model
 

(TREM), 208
 

TREM groups, 209
 

treatment 

approaches, 13
 

continuity, 106
 

culture, 92
 

criteria, 10
 

delivery changes, 10
 

failures, 145
 

innovations, 8–10
 

matching, 95, 97–99
 

models, 3, 152
 

of nicotine dependence, 343–347
 

outcomes, and posttraumatic stress 

disorder, 412
 

phases, 39
 

program, 33
 

teams, 397
 

treatment planning, 69–71, 95–96, 104. See
 

also discharge planning
 

case studies, 69, 70
 

development of, 107
 

during pregnancy, 205
 

involving clients in, 143
 

Triad Women’s Project, 211
 

Trull Foundation, 53
 

U

unemployment, 46
 

University of Medicine and Dentistry of New
 

Jersey Tobacco Program, 218
 

University of Washington, 185
 

URICA (University of Rhode Island Change
 

Assessment Scale), 68, 94, 495
 

U.S. Public Health Service Clinical Practice
 

Guidelines on Treating Tobacco Use and
 

Dependence, 218, 343
 

V
 

validity, assessment, 66
 

values, 56
 

van Ameringen Foundation, 53
 

Victorian Problem Gambling Family Impact
 

Scale, 431
 

violence, 3, 75
 

caused by alcohol consumption, 250
 

and pathological gambling, 432
 

and posttraumatic stress disorder, 411
 

and suicidality, 215
 

and women, 207
 

vocational rehabilitation, 46, 92, 398
 

vouchers, 122
 

558 Index
W

Walden House, 175
 

Wender Utah Rating Scale, 405
 

withdrawal symptoms
 

alcohol, 250
 

nicotine, 341
 

women, 73, 145
 

barriers to treatment, 203
 

and child care, 203
 

need for empirical information, 211
 

and pharmacologic considerations, 205
 

and postpartum depression, 206–207
 

and pregnancy, 205
 

and trauma, 205
 

and violence, 207
 

women, co­occurring disorders, and violence

study, 208–209

Women’s Support and Empowerment Center,
 

210
 

workforce development, 55
 

Y

youth, and suicidality, 215
 

Index 559
 
CSAT TIPs and Publications Based on TIPs

What Is a TIP?

Treatment Improvement Protocols (TIPs) are the products of a systematic and innovative process that brings together clinicians,

researchers, program managers, policymakers, and other Federal and non­Federal experts to reach consensus on state­of­the­art 

treatment practices. TIPs are developed under CSAT’s Knowledge Application Program to improve the treatment capabilities of the

Nation’s alcohol and drug abuse treatment service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket­sized booklet. Each Quick Guide is

divided into sections to help readers quickly locate relevant material. Some contain glossaries of terms or lists of resources. Page 

numbers from the original TIP are referenced so providers can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening instruments, checklists, and 

summaries of treatment phases. Printed on coated paper, each KAP Keys set is fastened together with a key ring and can be kept 

within a treatment provider’s reach and consulted frequently. The Keys allow you, the busy clinician or program administrator, to

locate information easily and to use this information to enhance treatment services.

Ordering Information

Publications may be ordered from or downloaded from SAMHSA’s Publications Ordering Web page at http://

store.samhsa.gov. Or, please call 1­877­SAMHSA­7 (1­877­726­4727) (English and Español).

TIP 1 State Methadone Treatment Guidelines—

Replaced by TIP 43

TIP 2 Pregnant, Substance­Using Women—

Replaced by TIP 51

TIP 3 Screening and Assessment of Alcohol­ and Other

Drug­Abusing Adolescents—Replaced by TIP 31

TIP 4 Guidelines for the Treatment of Alcohol and Other

Drug­Abusing Adolescents—Replaced by TIP 32

TIP 5 Improving Treatment for Drug­Exposed Infants—

BKD110

TIP 6 Screening for Infectious Diseases Among Substance

Abusers—Archived

TIP 7 Screening and Assessment for Alcohol and Other

Drug Abuse Among Adults in the Criminal Justice

System—Replaced by TIP 44

TIP 8 Intensive Outpatient Treatment for Alcohol and

Other Drug Abuse—Replaced by TIPs 46 and 47

TIP 9 Assessment and Treatment of Patients With

Coexisting Mental Illness and Alcohol and Other

Drug Abuse—Replaced by TIP 42

TIP 10 Assessment and Treatment of Cocaine­Abusing

Methadone­Maintained Patients—Replaced by TIP 43

TIP 11 Simple Screening Instruments for Outreach for

Alcohol and Other Drug Abuse and Infectious

Diseases—Replaced by TIP 53

TIP 12 Combining Substance Abuse Treatment With

Intermediate Sanctions for Adults in the Criminal

Justice System—Replaced by TIP 44

TIP 13 Role and Current Status of Patient Placement

Criteria in the Treatment of Substance Use

Disorders—BKD161

Quick Guide for Clinicians QGCT13

Quick Guide for Administrators QGAT13

KAP Keys for Clinicians KAPT13

TIP 14 Developing State Outcomes Monitoring Systems for

Alcohol and Other Drug Abuse Treatment—BKD162

TIP 15 Treatment for HIV­Infected Alcohol and Other Drug

Abusers—Replaced by TIP 37

TIP 16 Alcohol and Other Drug Screening of Hospitalized

Trauma Patients—(SMA) 12­3686

Quick Guide for Clinicians QGCT16

KAP Keys for Clinicians KAPT16

TIP 17 Planning for Alcohol and Other Drug Abuse

Treatment for Adults in the Criminal Justice

System—Replaced by TIP 44

TIP 18 The Tuberculosis Epidemic: Legal and Ethical Issues

for Alcohol and Other Drug Abuse Treatment

Providers—Archived

TIP 19 Detoxification From Alcohol and Other Drugs—

Replaced by TIP 45

TIP 20 Matching Treatment to Patient Needs in Opioid

Substitution Therapy—Replaced by TIP 43

561
TIP 21	 Combining Alcohol and Other Drug Abuse Treatment

With Diversion for Juveniles in the Justice System—

(SMA) 12­4073

Quick Guide for Clinicians and Administrators

QGCA21

TIP 22	 LAAM in the Treatment of Opiate Addiction—

Replaced by TIP 43

TIP 23	 Treatment Drug Courts: Integrating Substance Abuse

Treatment With Legal Case Processing—

(SMA) 12­3917

Quick Guide for Administrators QGAT23

TIP 24	 A Guide to Substance Abuse Services for Primary

Care Clinicians—(SMA) 08­4075

Concise Desk Reference Guide BKD123

Quick Guide for Clinicians QGCT24

KAP Keys for Clinicians KAPT24

TIP 25	 Substance Abuse Treatment and Domestic Violence—

(SMA) 12­4076

Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Treatment Providers

MS668

Linking Substance Abuse Treatment and Domestic

Violence Services: A Guide for Administrators MS667

Quick Guide for Clinicians QGCT25

KAP Keys for Clinicians (SMA) 12­3584

TIP 26	 Substance Abuse Among Older Adults—(SMA) 12­3918

Substance Abuse Among Older Adults: A Guide for

Treatment Providers MS669

Substance Abuse Among Older Adults: A Guide for

Social Service Providers MS670

Substance Abuse Among Older Adults: Physician’s

Guide MS671

Quick Guide for Clinicians QGCT26

KAP Keys for Clinicians KAPT26

TIP 27	 Comprehensive Case Management for Substance

Abuse Treatment—(SMA) 12­4215

Case Management for Substance Abuse Treatment: A

Guide for Treatment Providers MS673

Case Management for Substance Abuse Treatment: A

Guide for Administrators MS672

Quick Guide for Clinicians QGCT27

Quick Guide for Administrators QGAT27

TIP 28	 Naltrexone and Alcoholism Treatment—

Replaced by TIP 49

TIP 29	 Substance Use Disorder Treatment for People With

Physical and Cognitive Disabilities—(SMA) 12­4078

Quick Guide for Clinicians QGCT29

Quick Guide for Administrators (SMA) 08­3592

KAP Keys for Clinicians KAPT29

TIP 30	 Continuity of Offender Treatment for Substance Use

Disorders From Institution to Community—

(SMA) 12­3920
 

Quick Guide for Clinicians QGCT30
 

KAP Keys for Clinicians KAPT30
 

TIP 31	 Screening and Assessing Adolescents for Substance

Use Disorders—(SMA) 12­4079

See companion products for TIP 32.

TIP 32	 Treatment of Adolescents With Substance Use

Disorders—(SMA) 12­4080

Quick Guide for Clinicians QGC312

KAP Keys for Clinicians KAPT312

TIP 33	 Treatment for Stimulant Use Disorders—

(SMA) 09­4209
 

Quick Guide for Clinicians QGCT33
 

KAP Keys for Clinicians KAPT33
 

TIP 34	 Brief Interventions and Brief Therapies for Substance

Abuse—(SMA) 12­3952

Quick Guide for Clinicians QGCT34

KAP Keys for Clinicians KAPT34

TIP 35	 Enhancing Motivation for Change in Substance Abuse

Treatment—(SMA) 13­4212

Quick Guide for Clinicians—(SMA) 12­4097

KAP Keys for Clinicians (SMA) 12­4091

TIP 36	 Substance Abuse Treatment for Persons With Child

Abuse and Neglect Issues—(SMA) 12­3923

Quick Guide for Clinicians QGCT36

KAP Keys for Clinicians KAPT36

Helping Yourself Heal: A Recovering Woman’s 

Guide to Coping With Childhood Abuse Issues 

(SMA) 08­4132
 

Available in Spanish: PHD981S
 

Helping Yourself Heal: A Recovering Man’s Guide 

to Coping With the Effects of Childhood Abuse 

(SMA) 08­4134
 

Available in Spanish: PHD1059S
 

562
TIP 37	 Substance Abuse Treatment for Persons With

HIV/AIDS—(SMA) 12­4137

Quick Guide for Clinicians MS678

KAP Keys for Clinicians KAPT37

Drugs, Alcohol, and HIV/AIDS: A Consumer Guide

(SMA) 08­4127

Available in Spanish: PHD1134

Drugs, Alcohol, and HIV/AIDS: A Consumer Guide

for African Americans (SMA) 07­4248

TIP 38	 Integrating Substance Abuse Treatment and

Vocational Services—(SMA) 12­4216

Quick Guide for Clinicians QGCT38

Quick Guide for Administrators QGAT38

KAP Keys for Clinicians KAPT38

TIP 39	 Substance Abuse Treatment and Family Therapy—

(SMA) 12­4219

Quick Guide for Clinicians QGCT39

Quick Guide for Administrators QGAT39

TIP 40	 Clinical Guidelines for the Use of Buprenorphine in

the Treatment of Opioid Addiction—(SMA) 07­3939

Quick Guide for Physicians QGPT40

KAP Keys for Physicians KAPT40

TIP 41	 Substance Abuse Treatment: Group Therapy—

(SMA) 12­3991

Quick Guide for Clinicians (SMA) 12­4024

TIP 42	 Substance Abuse Treatment for Persons With CoOccurring Disorders—(SMA) 13­3992

Quick Guide for Clinicians (SMA) 07­4034

Quick Guide for Administrators (SMA) 12­4035

KAP Keys for Clinicians (SMA) 08­4036

TIP 43	 Medication­Assisted Treatment for Opioid Addiction

in Opioid Treatment Programs—(SMA) 08­4214

Quick Guide for Clinicians QGCT43

KAP Keys for Clinicians (SMA) 07­4108

TIP 44	 Substance Abuse Treatment for Adults in the Criminal

Justice System—(SMA) 13­4056

Quick Guide for Clinicians QGCT44

KAP Keys for Clinicians (SMA) 07­4150

TIP 45	 Detoxification and Substance Abuse Treatment—

(SMA) 13­4131

Quick Guide for Clinicians (SMA) 06­4225

Quick Guide for Administrators (SMA) 06­4226

KAP Keys for Clinicians (SMA) 06­4224

TIP 46	 Substance Abuse: Administrative Issues in Outpatient

Treatment—(SMA) 12­4157

Quick Guide for Administrators—(SMA) 07­4232

TIP 47	 Substance Abuse: Clinical Issues in Outpatient

Treatment—(SMA) 12­4182

Quick Guide for Clinicians—(SMA) 07­4233

KAP Keys for Clinicians—(SMA) 07­4251

TIP 48	 Managing Depressive Symptoms in Substance Abuse

Clients During Early Recovery—(SMA) 13­4353

TIP 49	 Incorporating Alcohol Pharmacotherapies Into

Medical Practice—(SMA) 12­4380

Quick Guide for Counselors (SMA) 10­4542

Quick Guide for Physicians (SMA) 10­4543

KAP Keys for Clinicians (SMA) 10­4544

TIP 50	 Addressing Suicidal Thoughts and Behaviors in

Substance Abuse Treatment—(SMA) 09­4381

TIP 51  Substance Abuse Treatment: Addressing the 

Specific Needs of Women—(SMA) 13­4426

TIP 52	 Clinical Supervision and Professional Development of

the Substance Abuse Counselor—(SMA) 09­4435

TIP 53	 Addressing Viral Hepatitis in People With Substance

Use Disorders—(SMA) 11­4656

TIP 54	 Managing Chronic Pain in Adults With or in Recovery

From Substance Use Disorders—(SMA) 12­4671

TIP 55	 Behavioral Health Services for People Who Are

Homeless—(SMA) 13­4734

TIP 56	 Addressing the Specific Behavioral Health Needs of

Men—(SMA) 13­4736

563
Substance Abuse Treatment 

For Persons With 

Co-Occurring Disorders 

This TIP, Substance Abuse Treatment for Persons With 

Co-Occurring Disorders, revises TIP 9, Assessment and Treatment 

of Patients With Coexisting Mental Illness and Alcohol and Other 

Drug Abuse. The revised TIP provides information about new 

developments in the rapidly growing field of co-occurring 

substance use and mental disorders and captures the state-ofthe-art in the treatment of people with co-occurring 

disorders. The TIP focuses on what the substance abuse treatment clinician needs to know and provides that information in 

an accessible manner. The TIP synthesizes knowledge and 

grounds it in the practical realities of clinical cases and real situations so the reader will come away with increased knowledge, 

encouragement, and resourcefulness in working with clients 

with co-occurring disorders. 

Collateral Products 

Based on TIP 42 

Quick Guide For Clinicians 

KAP Keys For Clinicians 

Quick Guide for Administrators 

Quick Guide for Mental Health Providers 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 

HHS Publication No. (SMA) 1-3992 

First Printed 2005 

Revised 2007, 2008, 2011, 2012 AND