Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness A Handbook for Mental Health Professionals Alan S Bellack Melanie E Bennett Jean S Gearon New York London Routledge is an imprint of the Taylor & Francis Group, an informa business Routledge Taylor & Francis Group Park Square Milton Park, Abingdon Oxon OX14 4RN Routledge Taylor & Francis Group 270 Madison Avenue New York, NY 10016 © 2007 by Taylor & Francis Group, LLC Routledge is an imprint of Taylor & Francis Group, an Informa business Printed in the United States of America on acid-free paper 10 International Standard Book Number-10: 0-415-95283-2 (Softcover) International Standard Book Number-13: 978-0-415-95283-5 (Softcover) No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe Library of Congress Cataloging-in-Publication Data Bellack, Alan S Behavioral treatment for substance abuse in people with serious and persistent mental illness : a handbook for mental health professionals / Alan S Bellack, Melanie E Bennett, Jean S Gearon p ; cm Includes bibliographical references ISBN 0-415-95283-2 (pb : alk paper) Drug abuse Treatment Behavior modification Mental illness Patients Medical care I Bennett, Melanie E II Gearon, Jean S III Title [DNLM: Substance-Related Disorders therapy Behavior Therapy methods Mental Disorders complications Schizophrenia complications Substance-Related Disorders complications WM 270 B4356b 2007] RC563.2.B45 2007 616.86’06 dc22 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the Routledge Web site at http://www.routledgementalhealth.com 2006014121 ASB: To Sonia McQuarters, who blossomed professionally with this project and who kept the machine running through thick and thin It would not have been possible without her MEB: To Stephen and Sondra Bennett for their help and support JSG: To Matthew, Vicky, and my brother Don for all their strength and courage CONTENTS PREFACE ix Part I INTRODUCTION TO TREATING PEOPLE WITH DUAL DISORDERS SCIENTIFIC BACKGROUND 13 TRAINING PHILOSOPHY AND GENERAL STRATEGIES 25 SOCIAL SKILLS TRAINING 37 ASSESSMENT STRATEGIES 49 Part II MOTIVATIONAL INTERVIEWING IN PEOPLE WITH SPMI 65 URINALYSIS CONTINGENCY AND GOAL SETTING 83 SOCIAL SKILLS AND DRUG REFUSAL SKILLS TRAINING 95 EDUCATION AND COPING SKILLS TRAINING 125 10 RELAPSE PREVENTION AND PROBLEM SOLVING 165 11 GRADUATION AND TERMINATION 223 Part III 12 DEALING WITH COMMON PROBLEM SITUATIONS 235 13 IMPLEMENTING BTSAS IN CLINICAL SETTINGS: STRATEGIES AND POTENTIAL MODIFICATIONS 251 REFERENCES 259 INDEX 265 vii PREFACE The seeds of this book were planted in Philadelphia in the early 1990s ASB and colleagues had been conducting clinical trials and psychopathology studies at Medical College of Pennsylvania (MCP) with people who had schizophrenia As was standard practice at the time, we excluded people from our studies who had comorbid drug abuse It was assumed that they were behaviorally difficult to engage, and that they had a different, more severe disease course with greater cognitive impairment MCP was located in central Philadelphia and, during the late 1980s and early 1990s, drug abuse, especially abuse of crack cocaine, was an epidemic in the area This tragic circumstance increasingly affected people with schizophrenia, and over time more and more patients were being excluded from our studies due to drug abuse Kim Mueser, PhD, a colleague at MCP, recognized the significance of this problem and was lead author on an early, seminal paper that identified the magnitude and possible causes of this problem (Mueser, Yarnold, & Bellack, 1992), and a subsequent paper that discussed the implications for treatment (Mueser, Bellack, & Blanchard, 1992) In examining the literature it quickly became apparent that there was no empirically sound treatment available for people with dual disorders and we began conceptualizing what an effective treatment might entail A fortuitous circumstance about the same time was that the National Institute of Drug Abuse (NIDA) issued an innovative program announcement for treatment development grants Most NIH funding mechanisms at the time required extensive pilot data, which required the availability of local resources In contrast, this mechanism was designed to provide pilot costs for investigators interested in developing new treatments: essentially venture capital ASB and MB submitted an application and were funded to develop an innovative program that we called Behavioral Treatment for Substance Abuse in Schizophrenia (BTSAS) Shortly after the grant was funded, MEB moved to New Mexico, and ASB moved to Baltimore, where he hired JSG to help run the project Preliminary data were sufficiently promising that we received funding for a competitive renewal in 1998 To our great good fortune MEB moved to Maryland at about the same time, and she rejoined our team This book is the culmination of 10 years of work It evolved gradually as we learned more about how to conduct the treatment We dropped some elements that did not work as planned or were not relevant to our subjects Similarly, we refined many elements and added others In many respects the consumers who volunteered for our studies were our tutors However, the changes have primarily been evolutionary rather than revolutionary The content of the current program is very similar to what we initially proposed, although it is much more clinically sophisticated In the course of conducting our studies we also expanded the treatment beyond schizophrenia to include other consumers with serious mental illness; hence, the current title: Behavioral Treatment for Substance Abuse by People with Serious and Persistent Mental Illness: A Handbook for Mental Health Professionals ix REFERENCES Addington, J., & el-Guebaly, N (1998) Group treatment for substance abuse in schizophrenia Canadian Journal of Psychiatry, 43(8), 843–845 Addis, M E (2002) Methods for disseminating research products and increasing evidence-based practice: promises, obstacles, and future directions Clinical Psychology: Science and Practice, 9(4), 367–368 Albanese, M J., Bartel, R L., Bruno, R F., Morgenbesser, M W., & Schatzberg, A F (1994) Comparison of measures used to determine substance abuse in an inpatient psychiatric sample American Journal of Psychiatry, 151(7), 1077–1078 American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (4th Ed., DSM-IV) Washington, DC: Author American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (4th Ed., Text Rev., DSM-IV) Washington, DC: Author Annis, H M., & Davis, C S (1989) Relapse prevention In R K Hester & W R Miller (Eds.), Handbook of alcoholism treatment approaches (pp 170–182) New York: Pergamon Appleby, L., Dyson, V., Altman, E., & Luchins, D J (1997) Assessing substance use in multiproblem patients: Reliability and validity of the Addiction Severity Index in a mental hospital population Journal of Nervous and Mental Disease, 185(3), 159–165 Appleby, L., Dyson, V., Altman, E., McGovern, M P., & Luchins, D J (1996) Utility of the Chemical Use, Abuse, and Dependence scale in screening patients with severe mental illness Psychiatric Services, 47(6), 647–649 Backer, T (1995) Assessing and enhancing readiness for change: Implications for technological transfer In T Backer, S David, & D Soucy (Eds.), Reviewing the behavioral science knowledge base on technology transfer (pp 21–41) (NIDA Research Monograph 155, NIDA publication No 95-4035) Rockville, MD: National Institute on Drug Abuse Backer, T (2000) The failure of success: Challenges of disseminating effective substance abuse prevention programs Journal of Community Psychology, 28, 363–373 Backer, T., Liberman, R P., & Kuehnel, T G (1986) Dissemination and adoption of innovative psychosocial interventions Journal of Consulting and Clinical Psychology, 54, 111–118 Baker, A., Boggs, T G., & Lewin, T J (2001) Randomized controlled trial of brief cognitive-behavioural interventions among regular users of amphetamine Addiction, 96, 1279–1287 Bandura, A (1969) Principles of behavior modification New York: Holt, Rinehart, & Winston Barrowclough, C., Haddock, G., Tarrier, N., Lewis, S., Moring, J., O’Brien, R., et al (2001) Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders American Journal of Psychiatry, 158, 1706–1713 Bellack, A S (2004) Skills training for people with severe mental illness Psychiatric Rehabilitation Journal, 27, 375–391 Bellack, A S., Bennett, M E., Gearon, J S., Brown, C H., & Yang, Y (2006) A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness Archives of General Psychiatry, 63, 426–532 Bellack, A S., & Blanchard, J J (1993) Schizophrenia: Psychopathology In A S Bellack & M Hersen (Eds.), Psychopathology in adulthood: An advanced tex (pp 216–233) Needham, MA: Allyn & Bacon Bellack, A S., & DiClemente, C C (1999) Treating substance abuse among patients with schizophrenia Psychiatric Services 50, 75–80 Bellack, A S., & Gearon J S (1998) Substance abuse treatment for people with schizophrenia Addictive Behaviors, 6, 749–766 Bellack, A S., Gold, J M., & Buchanan, R W (1999) Cognitive rehabilitation for schizophrenia: problems, prospects, and strategies Schizophrenia Bulletin, 25(2), 257–274 Bellack, A S., Mueser, K T., Gingerich, S., & Agresta, J (1997) (Eds.) Social skills training for schizophrenia: A step-by-step guide New York: Guilford Bellack, A S., Mueser, K T., Gingerich, S., & Agresta, J (2004) Social skills training for schizophrenia: A step-by-step guide (2nd ed.) New York: Guilford 259 Bennett, M E., & Barnett, B (2003) Dual-diagnosis In M Hersen & S M Turner (Eds.), Adult psychopathology and diagnosis (4th ed., pp 36–71) New York: Wiley Bergman, H C., & Harris, M (1985) Substance abuse among young adult chronic patients Psychological Rehabilitation Journal, 9, 49–54 Biegel, D., Kola, L., Ronis, R., Boyle, P., Delos Reyes, C., & Wieder, B (2003) The Ohio substance abuse and mental illness coordinating center of excellence: Implementation support for evidenced based practice Research on Social Work Practice, 13, 531–545 Bien, T H., Miller, W R., & Tonigan, J S (1993) Brief interventions for alcohol problems: A review Addiction, 88, 315–336 Breakey, W R., Calabrese, L., Rosenblatt, A., & Crum, R M (1998) Detecting alcohol use disorders in the severely mentally ill Community Mental Health Journal, 34(2), 165–174 Carbonari, J P., DiClemente, C C., & Zweben, A (1994) A readiness to change scale: Its development, validation and usefulness Presented at the annual meeting of the AABT, San Diego, CA Carey, K B., Carey, M P., Maisto, S A., & Purnine, D M (2002) The feasibility of enhancing psychiatric outpatients’ readiness to change their substance use Psychiatric Services, 53, 602–608 Carey, K B., Cocco, K M., & Correia, C J (1997) Reliability and validity of the Addiction Severity Index among outpatients with severe mental illness Psychological Assessment, 9(4), 422–428 Carey, K B., & Correia, C J (1998) Severe mental illness and addictions: Assessment considerations Addictive Behaviors, 23(6), 735–748 Carey, M P., Carey, K B., & Kalichman, S C (1997) Risk for human immunodeficiency virus (HIV) infection among persons with severe mental illnesses Clinical Psychology Review, 17, 271–291 Carroll, K M., Power, M E D., Bryant, K., & Rounsaville, B J (1993) One-year follow-up status of treatment-seeking cocaine abusers: Psychopathology and dependence severity as predictors of outcome Journal of Nervous and Mental Disease, 181, 71–79 Carroll, K M., Rounsaville, B J., & Gawin, F H (1991) A comparative trial of psychotherapies for ambulatory cocaine abusers: Relapse prevention and interpersonal psychotherapy American Journal of Drug and Alcohol Abuse, 17, 229–247 Chamberlain P (2003) Treating chronic juvenile offenders: Advances made through the Oregon multidimensional treatment foster case model Law and public policy Washington, DC: American Psychological Association Chiauzzi, E J (1991) Preventing relapse in the addictions: A biopsychosocial approach New York: Pergamon Chorpita, B F., Yim, L M., Donkervoet, J C., Arensdorf, A., Amundsen, M J., & McGee, C (2002) Toward large scaled implementation of empirically supported treatment for children: A review and observations by the Hawaii Empirical Basis to Services Task Force Clinical Psychology: Science and Practice, 9, 165–190 Cocco, K M., & Carey, K B (1998) Psychometric properties of the Drug Abuse Screening Test in psychiatric outpatients Psychological Assessment, 10(4), 408–414 Corse, S J., Herschinger, N B., & Zanis, D A (1995) The use of the ASI with persons with severe mental illness: Face validity Psychosocial Rehabilitation Journal, 19(1), 9-18 Daley, D C., Salloum, I M., Zuckoff, A., Kirisci, L., & Thase, M E (1998) Increasing treatment adherence among outpatients with depression and cocaine dependence: Results of a pilot study American Journal of Psychiatry, 155, 1611–1613 Daley, D C., & Zuckoff, A (1998) Improving compliance with the initial outpatient session among discharged inpatient dual diagnosis clients Social Work, 43, 470–473 Dawe, S., Seinen, A., & Kavanagh, D (2000) An examination of the utility of the AUDIT in people with schizophrenia Journal of Studies on Alcohol, 61(5), 744–750 DiClemente, C C., Carbonari, J P., Montgomery, R P G., & Hughes, S O (1994) The Alcohol Abstinence Self-Efficacy scale Journal of Studies on Alcohol, 55, 141–148 DiClemente, C C., Fairhurst, S K., & Piotrowski, N A (1995) Self-efficacy and addictive behaviors In J Maddux (Ed.), Self-efficacy, adaptation and adjustment: Theory, Research and Application New York: Plenum DiClemente, C C., & Hughes, S O (1990) Stages of change profiles in outpatient alcoholism treatment Journal of Substance Abuse, 2, 217–235 Dixon, L (1999) Dual diagnosis of substance abuse in schizophrenia: Prevalence and impact on outcomes Schizophrenia Research, 35, S93–S100 Dixon, L., Haas, G., Weiden, P., Sweeney, J., & Frances, A (1990) Acute effects of drug abuse in schizophrenic patients: Clinical observations and patients’ self-reports Schizophrenia Bulletin, 16(1), 69–79 Drake, R E., & Bellack, A S (2005) Psychiatric rehabilitation In B J Sadock & V A Sadock (Eds.), Kaplan and Sadock’s comprehensive textbook of psychiatry (pp 1476–1486) Philadelphia: Lippincott, Williams & Wilkins Drake, R E., Essock, S M., Shaner, A., Carey, K B., Minkoff, K., Kola, L., Lynde, D., Osher, F C., Clark, R E., & Rickards, L (2001) Implementing dual diagnosis services for clients with severe mental illness Psychiatric Services, 52, 469–476 Drake, R E., McHugo, G J., & Noordsy, D L (1993) Treatment of alcoholism among schizophrenic outpatients: 4-year outcomes American Journal of Psychiatry, 150, 328–329 Drake, R E., Mueser, K T., Brunette, M F., & McHugo, G J (2004) A review of treatments for people with severe mental illnesses and cooccurring substance use disorders Psychiatric Rehabilitation Journal, 27, 360–374 Drake, R E., Mercer-McFadden, C., Mueser, K T., McHugo, G.J., & Bond, G.R (1998) Review of integrated mental health and substance abuse treatment for patients with dual disorders Schizophrenia Bulletin, 24, 589–608 Drake, R E., Osher, F C., Noordsy, D L., Hurlburt, S C., Teague, G B., & Beaudett, M S (1990) Diagnosis of alcohol use disorders in schizophrenia Schizophrenia Bulletin, 169(1), 57–67 Dumaine, M L (2003) Meta-analysis of interventions with co-occurring disorders of severe mental illness and substance abuse: Implications for social work practice Research on Social Work Practice, 13, 142–165 First, M B., Spitzer, R L., Gibbon, M., & Williams, J B W (1994) Structured clinical interview for DSM-IV Axis I disorders New York: Biometrics Research Department, New State Psychiatric Institute 260 References Gearon, J S., Bellack, A S., Rachbeisel, J., & Dixon, L (2001) Drug-use behavior and correlates in people with schizophrenia Addictive Behaviors, 26(1), 51–61 Gearon, J S., Kaltman, S I., Brown, C., & Bellack, A S (2003) Traumatic life events and PTSD in substance disordered women with schizophrenia Psychiatric Services, 54, 523–528 Goisman, R, Warshaw, M., & Keller, M (1999) Psychosocial treatment prescriptions for generalized anxiety, panic disorder and social phobia, 1991–1996 American Journal of Psychiatry, 156, 1819–1821 Goldman, H., Drake, R., Gorman, P., Hogan, M., Hyde, P., & Morgan, O (2001) Policy Implications for implementing evidenced-based practices Psychiatric Services, 52, 591–1597 Grant, B F., & Harford, T C (1995) Comorbidity between DSM-IV alcohol use disorders and major depression: Results of a national survey Drug and Alcohol Dependence, 39, 197–206 Grella, C E (1996) Background and overview of mental health and substance abuse treatment systems: Meeting the needs of women who are pregnant or parenting Journal of Psychoactive Drugs, 28(4), 319–343 Haddock, G., Barrowclough, C., Tarrier, N., Moring, J., O’Brien, R., Schofield, N et al (2003) Cognitive-behavioural therapy and motivational intervention for schizophrenia and substance misuse 18-month outcomes of a randomized controlled trial British Journal of Psychiatry, 183, 418–426 Hall, S M., Wasserman, D A., & Havassy, B E (1991) Relapse prevention In R.W Pickens, C G Leukefeld, & C R Schuster (Eds.), Improving drug abuse treatment (pp 279–292) Rockville, MD: National Institute on Drug Abuse NIDA Research Monograph No 106 Heather, N (1989) Brief intervention strategies In R K Hester & W R Miller (Eds.), Handbook of alcoholism treatment approaches (pp 93–116) New York: Pergamon Henggeler, S W., Schoenwald, S., Liao, J., Letourneau, E., & Edwards, D (2002) Transporting efficacious treatments to field settings: The link between supervisory practices and therapist fidelity in MST programs Journal of Clinical Child and Adolescent Psychology, 31, 155–167 Hesse, M (2006) The Readiness Ruler as a measure of readiness to change poly-drug use in drug abusers Harm Reduction Journal, 3, 1–5 Higgins, S T., Alessi, S M., & Dantona, R L (2002) Voucher-based incentives A substance abuse treatment innovation Addictive Behaviors, 27(6), 887–910 Jerrell, J M., & Ridgely, M R (1995) Comparative effectiveness of three approaches to serving people with severe mental illness and substance abuse disorders Journal of Nervous and Mental Disease, 183, 566–576 Kemp, R., Hayward, P., Applewhaite, G., et al (1996) Compliance therapy in psychotic patients: Randomised controlled trial British Medical Journal, 312, 345–349 Kemp, R., Kirov, G., Everitt, B., Hayward, P., & David, A (1998) Randomised controlled trial of compliance therapy: 18-month follow-up British Journal of Psychiatry, 172, 413–419 LaForge, R G., Maddock, J E., & Rossi, J S (1999) Replication of the temptations and decisional balance instruments for heavy, episodic drinking on an adult sample [Abstract] Annals of Behavioral Medicine, 21, S67 Lehman, A F (1988) A quality of life interview for the chronically mentally ill Evaluation and Program Planning, 11, 51–62 Lehman, A F., Dixon, L.B., Kernan, E., DeForge, B.R., & Postrado, L.T.(1997) A randomized trial of assertive community treatment for homeless persons with severe mental illness Archives of General Psychiatry, 54, 1038–1043 Lehman, A F., Kreyenbuhl, J., Buchanan, R.W., Dickerson, F A., Dixon, L B., Goldberg, R., et al (2004) The schizophrenia patient outcomes research team (PORT): Updated treatment recommendations 2003 Schizophrenia Bulletin, 30, 193–217 Lehman, A F., Myers, C P., Dixon, L B., & Johnson, J L (1994) Defining subgroups of dual diagnosis patients for service planning Hospital and Community Psychiatry, 45, 556–561 Lehman, A F., Myers, C.P., Dixon, L B., & Johnson, J L (1996) Detection of substance use disorders among psychiatric inpatients Journal of Nervous and Mental Disease, 184(4), 228–233 Lehman, W., Greener, J., & Simpson, D (2002) Assessing organizational readiness for change Journal of Substance Abuse Treatment, 22, 197–209 Ley, A., Jeffery, D P., McLaren, S., & Siegfried, N (2003) Psychosocial treatment programmes for people with both severe mental illness and substance misuse The Cochrane Library, 3, 1–37 Lieberman, J A., Kane, J M., & Alvir, J (1987) Provocative tests with psychostimulant drugs in schizophrenia Psychopharmacology, 91, 415–433 Marlatt, G A., & Gordon, G R (1985) Relapse prevention: Maintenance strategies in the treatment of addictive behaviors New York: Guilford Martino, S., Carroll, K M., O’Malley, S S., & Rounsaville, B J (2000) Motivational interviewing with psychiatrically ill substance abusing patients American Journal on Addictions, 9, 88–91 McCrady, B S (1993) Alcoholism In D H Barlow (Ed.), Clinical handbook of psychological disorders (2nd ed., pp 362–395) New York: Guilford McLellan, A T., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., et al (1992) Addiction Severity Index (5th ed.) Journal of Substance Abuse Treatment, 9, 199–213 McLellan, A T., Luborsky, L., Woody, G E., & O’Brien, C P (1980) An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index Journal of Nervous and Mental Disease, 168, 26–33 McLellan, A T., Luborsky, L., Woody, G E., O’Brien, C P., & Druley, K A (1983) Predicting response to alcohol and drug abuse treatments Role of psychiatric severity Archives of General Psychiatry, 40, 620–625 Meir, V J., & Hope, D A (1998) Assessment of social skills In A S Bellack & M Hersen (Eds.), Behavioral assessment (4th ed., pp 232–255) Needham Heights, MA: Allyn & Bacon Miller, W R (1992) The effectiveness of treatment for substance abuse: Reasons for optimism Journal of Substance Abuse Treatment, 9, 93–102 Miller, W R (1995) Increasing motivation for change In R K Hester & W R Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (2nd ed., pp 89–104) Needham Heights, MA: Allyn & Bacon References 261 Miller, W R (2000) Rediscovering fire: Small interventions, large effects Psychology of Addictive Behaviors, 14(1), 6–18 Miller, W R, Andrews, N R., Wilbourne, P., & Bennett, M E (1998) A wealth of alternatives: Effective treatments for alcohol problems In W R Miller & N Heather (Eds.), Treating addictive behaviors (2nd ed., pp 203–216) New York: Plenum Press Miller, W R., Benefield, R G., & Tonigan, J S (1993) Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles Journal of Consulting and Clinical Psychology, 61(3), 455–461 Miller, W R, Brown, J M., Simpson, T L., Handmaker, N S., Bien, T H., Luckie, L F., Montgomery, H A., Hester, R K., & Tonigan, J S (1995) What works? A methodological analysis of the alcohol treatment outcome literature In R K Hester & W R Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (2nd ed., pp 12–44) Needham Heights, MA: Allyn & Bacon Miller, W R., & Heather, N (1998) (Eds.) Treating addictive behaviors (2nd ed.) New York: Plenum Press Miller, W R., & Rollnick, S (1991) Motivational interviewing: Preparing people to change addictive behaviors New York: Guilford Moggi, F., Ouimette, P C., Finney, J W., & Moos, R H (1999) Effectiveness of treatment for substance abuse and dependence for dual diagnosis patients: A model of treatment factors associated with one-year outcomes Journal of Studies on Alcohol, 60(6), 856–866 Monti, P M., Abrams, D B., Kadden, R M., & Cooney, N L (1989) Treating alcohol dependence: A coping skills training guide New York: Guilford Mueser, K T., & Bellack, A S (1998) Social skills and social functioning In K T Mueser & N Tarrier (Eds.), Handbook of social functioning in schizophrenia (pp 79–96) Needham Heights, MA: Allyn & Bacon Mueser, K T., Bellack, A S., & Blanchard, J J (1992) Comorbidity of schizophrenia and substance abuse: Implications for treatment Journal of Consulting and Clinical Psychology, 60(6), 845–856 Mueser, K T., Bennett, M., & Kushner, M G (1995) Epidemiology of substance use disorders among persons with chronic mental illnesses In A F Lehman & L B Dixon (Eds.), Double jeopardy: Chronic mental illness and substance use disorders (Vol 3, pp 9–25) Longhorne, PA: Harwood Academic Mueser, K T., Drake, R E., & Wallach, M A (1998) Dual diagnosis: A review of etiological theories Addictive Behaviors, 23, 717–734 Mueser, K T., Noordsy, D L., Drake, R E., & Fox, L (2003) Integrated treatment for dual disorders: A guide to effective practice New York: Guilford Mueser, K T., Yarnold, P R., & Bellack, A S.(1992) Diagnostic and demographic correlates of substance abuse in schizophrenia and major affective disorder Acta Psychiatrica Scandinavica, 85, 48–55 Mueser, K T., Yarnold, P R., Levinson, D F., Singh, H., Bellack, A S., Kee, K., Morrison, R L., & Yadalam, K G (1990) Prevalence of substance abuse in schizophrenia: Demographic and clinical correlates Schizophrenia Bulletin, 16, 31–56 Newman, F (1999) The whole lesbian sex book San Francisco: Cleis Press Peniston, E G (1988) Evaluation of long-term therapeutic efficacy of behavior modification program with chronic male psychiatric inpatients Journal of Behavior Therapy and Experimental Psychiatry, 19, 95–101 Petry, N M (2000) A comprehensive guide to the application of contingency management procedures in clinical settings Drug and Alcohol Dependence, 58, 9–25 Polcin, D L (1992) Issues in the treatment of dual diagnosis clients who have chronic mental illness Professional Psychology: Research and Practice 23(1), 30–37 Prochaska, J O., & Diclemente, C C (1982) Transtheoretical therapy: Toward a more integrative model of change Psychotherapy: Theory, Research, and Practice, 19, 276–288 Prochaska, J O., Velicer, W F., Rossi, J S., Goldstein, M G., Marcus, B H., Rakowski, W., et al (1994) Stages of change and decisional balance for 12 problem behaviors Health Psychology, 13(1), 39–46 Project MATCH Research Group (1997) Matching alcoholism treatments to client heterogeneity: Project MATCH post treatment drinking outcomes Journal of Studies on Alcohol, 58(1), 7–29 Regier, D A., Farmer, M E., Rae, D S., Locke, B Z., Keith, S J., Judd, L L., et al (1990) Comorbidity of mental disorders with alcohol and other drug abuse Journal of the American Medical Association, 264, 2511–2518 Ridgely, M S., Goldman, H H., & Willenbring, M (1990) Barriers to the care of persons with dual diagnoses: Organizational and financing issues Schizophrenia Bulletin, 16(1), 123–132 Ridgely, M S., Lambert, D., Goodman, A., Chichester, C S., & Ralph, R (1998) Interagency collaboration in services for people with co-occurring mental illness and substance use disorder Psychiatric Services, 49, 236–238 Rogers, E (1995) Diffusion of preventive innovations Addictive Behaviors, 27, 989–993 Roll, J M., Chermack, S T., & Chudzynski, J E (2004) Investigating the use of contingency management in the treatment of cocaine abuse among individuals with schizophrenia: A feasibility study Psychiatry Research, 125, 61–64 Rosenberg, S D., Drake, R E., Wolford, G L., Mueser, K T., Oxman, T E., Vidaver, R M., et al (1998) Dartmouth Assessment of Lifestyle Instrument (DALI): A substance use disorder screen for people with severe mental illness American Journal of Psychiatry, 155(2), 232–238 Saunders, J B., Aasland, O G., Babor, T F., De La Fuente, J R., & Grant, M (1993) Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption: II Addiction, 88, 791–804 Saunders, B., Wilkinson, C., & Phillips, M (1995) The impact of a brief motivational intervention with opiate users attending a methadone programme Addiction, 90, 415–424 Schuckit, M A (1983) Alcoholism and other psychiatric disorders Hospital and Community Psychiatry, 34(11), 1022–1027 Searles, J S., Alterman, A I., & Purtill, J J (1990) The detection of alcoholism in hospitalized schizophrenics: A comparison of the MAST and the MAC Alcoholism: Clinical and Experimental Research, 14(4), 557–560 Selzer, M (1971) The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument American Journal of Psychiatry, 127, 1653–1658 262 References Shaner, A., Robert, L J., Eckman, T A., Tucker, D E., Tsuang, J W., Wilkins, J N., & Mintz, J (1997) Monetary reinforcement of abstinence from cocaine among mentally ill patients with cocaine dependence Psychiatric Services, 48, 807–810 Sigmon, S C., Steingard, S., Badger, G J., Anthony, S L., & Higgins, S T (2000) Contingency reinforcement of marijuana abstinence among individuals with serious mental illness: A feasibility study Experimental and Clinical Psychopharmacology, 8, 509–517 Skinner, H (1982) The Drug Abuse Screening Test Addictive Behaviors, 7, 363–371 Sobell, L C., & Sobell, M B (1992) Timeline follow-back: A technique for assessing self-reported alcohol consumption In R Z Litten & J P Allen (Eds.), Measuring alcohol consumption: Psychosocial and biochemical methods (pp 41–72) Totowa, NJ: Humana Press Stephens, R S., Roffman, R A., & Curtin, L (2000) Comparison of extended versus brief treatments for marijuana use Journal of Consulting and Clinical Psychology, 68, 898–908 Stotts, A M., Schmitz, J M., Rhoades, H M., & Grabowski, J (2001) Motivational interviewing with cocaine-dependent patients: A pilot study Journal of Consulting and Clinical Psychology, 69, 858–862 Swanson, A J., Pantalon, M V., & Cohen, K R (1999) Motivational interviewing and treatment adherence among psychiatric and dually diagnosed patients Journal of Nervous and Mental Disease, 187, 630–635 Timko, C., & Moos, R H (2002) Symptom severity, amount of treatment, and 1-year outcomes among dual diagnosis patients Administrative and Policy in Mental Health, 30, 35–54 Toland A M., Moss, H B (1989) Identification of the alcoholic schizophrenic: Use of clinical laboratory tests and the MAST Journal of Studies on Alcohol, 50(1), 49–53 Torrey, W., Drake, R., Dixon,L., Burns, B., Flynn, L., & Rush, A J (2001) Implementing evidenced-based practices for persons with server mental illnesses Psychiatric Services, 5, 45–50 Tracy, J I., Josiassen, R C., & Bellack, A S (1995) The neuropsychology of dual diagnosis: Understanding the combined effects of schizophrenia and substance use disorders Clinical Psychology Review, 15, 67–97 U.S Department of Health and Human Services (1999) Mental Health: A report of the Surgeon General Rockville, MD: U.S Department of Health and Human Services National Institute of Health, National Institute of Mental Health Velicer, W F., DiClemente, C C., Prochaska, J O., & Brandenberg, N (1985) Decisional balance measure for assessing and predicting smoking status Journal of Personality and Social Psychology, 48, 1279–1289 Wilkins, J N., Shaner, A L., Patterson, C M., Setoda, D., & Gorelick, D (1991) Discrepancies between patient report, clinical assessment, and urine analysis in psychiatric patients during inpatient admission Psychopharmacology Bulletin, 27(2), 149–154 Wiltsey Stirman, S, Crits-Christoph, P., & DeRubeis, R J (2004) Achieving successful dissemination of empirically supported psychotherapies: A synthesis of dissemination theory Clinical Psychology: Science and Practice, 11(4), 343–359 Zanis, D A., McLellan, A T., & Corse, S (1997) Is the Addiction Severity Index a reliable and valid instrument among clients with severe and persistent mental illness and substance abuse disorders? Community Mental Health Journal, 33(3), 213–227 References 263 INDEX A Abstinence, goals, Abstinence model, Abstraction, 29 Active outreach programs, 17–18 Addictive behaviors, change difficulties, 29–30 Alcohol abuse, see also Substance abuse comorbid alcohol use/abuse/dependence, 240–241 Anger management, skills sheet, 216–217 Assertive community treatment, 17, 18 Assertiveness training, skills sheet, 214–215 Assessments, 49–62 assessor related factors, 50 BTSAS, 51–62 assessing attendance at each BTSAS session, 59 assessing drug use at each BTSAS session, 60 assessing group participation at each BTSAS session, 60, 61–62 baseline level of functioning establishment, 56–57 end of treatment, 60 evaluating readiness to change, 57–59 follow-up, 60 integrated assessment for BTSAS referrals, 56 integrated assessment for general functioning and motivation to change, 59 interview measures, 55–56 recent use, 53–55 recommended assessment points, 52 referral to BTSAS, 52, 52 severe and persistent mental illness and substance use disorders, 53–55 start of treatment/first motivational interview, 52, 56–59 substance related negative consequences, 55 during treatment, 59–60 feedback from pretreatment, 67–70 illness related factors, 49–50 implications, 51 measures related factors, 50–51 poly-substance abuse, 245 Attendance, 238–239 Attention, 237–238 Audiovisuals, 29 Avoidance coping, 132, 176 skills sheet, 148–149 B Behaviorally based strategies, 22 Behavioral response, 37 Behavioral treatment for substance abuse by people with SPMI (severe and persistent mental illness), seeBTSAS Boredom relapse prevention and problem solving, 170 skills sheet, 186–187 Brief interventions, 19 BTSAS adaptations, 251–254 ambivalence about committing to treatment, 238 assessments, 51–62 assessing attendance at each BTSAS session, 59 assessing drug use at each BTSAS session, 60 assessing group participation at each BTSAS session, 60, 61–62 assessment during treatment, 59–60 baseline level of functioning establishment, 56–57 end of treatment, 60 evaluating readiness to change, 57–59 follow-up, 60 integrated assessment for BTSAS referrals, 56 integrated assessment for general functioning and motivation to change, 59 interview measures, 55–56 recent use, 53–55 recommended assessment points, 52 referral to BTSAS, 52, 52 severe and persistent mental illness and substance use disorders, 53–55 start of treatment/first motivational interview, 52, 56–59 substance related negative consequences, 55 atmosphere, broad-based treatment, 19–20 cognitive impairment, common problems in conducting groups, 235–239 community clinic strategies, 254–257 integration into clinic services, 254–255 components, 7, 20–24, 25–28 controlled trial, 9–11 core characteristics, 14–20 development, 7, 8–9 diagnostically homogenous vs heterogenous groups, 251–252 difficulty leaving BTSAS, 224 empirical support for, 8–11 enhancing motivation, 18–19 following group format, 236 goals, group format, 33 group size, 252 265 BTSAS (continued) highly structured, integrated treatment, 19–20 managed care limitations on sessions per week, 252–253 modifications, 251–254 one vs two therapists, 253–254 overview, 25–28 philosophy, 14–20 program duration, 4–5 reluctance to role-play, 236–237 scientific background, 13–24 session structure, 26 Supportive Treatment for Addiction Recovery (STAR), results compared, 9–10 tailoring treatment to, 32–33 new members, 32–33 teaching members to be good group participants, 33–34 teaching skills, 18–19 training format, 7–8 training philosophy, 28–31 treatment referral, 229–230 C Case management, 17, 18 Certificate of Achievement, 231 Change models, 16–17 motivation, 240 readiness, 16 stages, 16, 240 Coaching, 43 Cognitive impairment, 6, 29, 237–238 BTSAS, Condoms, 129–130, 155–158 Confidentiality, 34 Contingency management, 21 Co-occurring psychiatric and substance disorders, see Dual disorders Coordinator, 31–32 Coping skills, 27, 131–133 cravings, 131–132 habits, 131–132 high-risk situations, 131–132 instructions to therapists, 131 training, 23 triggers, 131–132 Coping strategies, identification of most useful, 227–228 Costs, 256 Cravings, skills sheet, 143–145 Crisis situations, 247–250 Criticism, 34 D Depression relapse prevention and problem solving, 171 skills sheet, 188–191 Distractibility, 237–238 Dropping out, 224–225, 239 Drug refusal skills, 175–176 low functioning and symptomatic clients, 106–107 maintaining interest, 107–108 reinforcement, 107–108 skills sheet, 115–117, 150–151 leaving, 123–124 266 Index offering alternative, 118–120 request person stop asking, 121–122 talking to drug dealer, 123–124 talking to stranger, 123–124 social skills training, 100–101, 102–105 drug dealers, 103 friends/family, 103 procedures, 102–103 rationale, 102–103 refusing and leaving situation, 104 refusing and offering alternative, 103–104 refusing and requesting person not ask to use drugs, 104 tailoring skills to different clients, 104–105 Drug withdrawal, 249 Dual diagnosis, see Dual disorders Dual disorders comorbid alcohol use/abuse/dependence, 240–241 consequences, other substances of abuse, 168–170 pattern of use, prevalence, randomized trials of psychosocial treatments, risks, secondary drug use, 242–243 substance use impact on symptoms, 128 supersensitivity model, 3–4 treatment of substance abuse, 4–5 difficulties of, 6–7 traditional service models, treatment results research, E Educational training, 22–23, 27, 126–130 instructions to therapists, 126 Empathy, 15 Employment skills, skills sheet, 218–220 Escape coping, 132–133, 176 skills sheet, 150–151 Expressive skills, 37 External contingencies, use of, 17–18 F Feedback, 33–34 social skills training, 101–102 Female condoms, 156–158 G Generalization, 40 Goal setting, 26, 84, 90–94 abstinence, ambivalence about committing to treatment, 238 BTSAS, developing goal, 90–91 form, 92–93 harm avoidance model, motivational interviewing follow-up session, 74–75 initial session, 70–71 problem-solving barriers, 91–92 reviewing goal between sessions, 92 review of reasons for staying clean or cutting down, 91 sample, 93–94 termination, 228–229 Graduation, 28 informing clients of their progress, 223–224 issues, 223–224 Graduation party, 130 Group leader, 31 Group members cohesion, 34 guidelines, 34 Group rules, 34 H Habits, skills sheet, 143–145 Harm avoidance model, goals, Harm reduction model, applied to goal drug, 239–240 Hepatitis prevention, 130 prevention skills sheet, 161–164 symptoms, 162 types, 162 Hepatitis C, 128–130 High-risk situations, 178–179 motivation, 172 skills sheet, 143–145 other substance use, 183–185 HIV, 128–130 definitions, 129 reducing HIV risk, 129–130 risky behaviors, 129 skills sheet definitions, 152–154 demonstrating condom use, 155–158 practice role-playing, 159–160 reducing risk, 155–158 risky behaviors, 152–154 transmission, 152–154 teaching condom use, 129–130 transmission, 129 Housing, loss of, 247–248 I Integrated treatment, 13 BTSAS, 19–20 J Job interview preparation, skills sheet, 218–220 Job training, skills sheet, 218–220 L Lapses, 23, 168 defined, skills sheet, 180–182 M Making plans with friend skills sheet, 113–114 social skills training, 98–100 Memory, 237–238 Mental health professionals, working with, 255–256 Mental illness, skills sheet, biological bases, 136–139 Mentally ill chemical abusers, seeDual disorders Modeling, 39 Money management, 172 skills sheet, 202–206 Motivation, change, 240 high-risk situations, 172 shifts, 238 skills sheet, 198–201 Motivational interviewing, 20–21, 25–26, 65–81 effectiveness, 20–21 elements, 20 examples, 75–80 follow-up motivational interviewing sessions, 71–75 discussion of negative consequences, 72–73 feedback, 72 introduction, 72 listing of helpful strategies, 74 things that have improved, 73–74 goal setting follow-up session, 74–75 initial session, 70–71 initial motivational interviewing, 66–71 assessment feedback, 67–70 discussion of negative consequences, 67 introduction, 66–67 objective, 66 N Negative affect, relapse prevention and problem solving, 170–171 O Open enrollment, termination, 224 Overlearning, 7, 39–40 P Partner using drugs, skills sheet, 210–211 Persistence, 30–31, 246–247 practical persistence, 18 Poly-substance abuse assessment, 245 persistence, 246–247 poly-substance dependence, 241–242 reinforcement, 245–246 secondary drug use, 242–243 strategies, 240–247 treatment strategies, 243–247 Practice, 29 Presenter, 31 Problem solving, 27 Prompting, 43 Psychotherapy, drawbacks, 28 R Reinforcement, 30, 39 drug refusal skills, 107–108 poly-substance abuse, 245–246 Relapse prevention, 23–24, 27 Relapse prevention and problem solving, 165–174 as applicable to severe and persistent mental illness clients, 166 boredom, 170 continued skills building, 174 coping with lapses, 168 coping with symptoms and side effects, 171–172 depression, 171 negative affect, 170–171 optional modules, 172–174 other substances of abuse, 168–170 skills sheet Index 267 Relapse prevention and problem solving (continued) high-risk situations, 178–179 review of drug refusal and coping skills, 175–177 social situations impacting drug use, 173 social skills, 173–174 standard modules, 167–172 stress, 171 unit content, 166–167 Relapses, defined, Relaxation training, skills sheet, 221–222 Role-playing reluctance, 236–237 safe sex, 130 S Safe sex, role-playing, 130 Schizophrenia skills sheet, biological bases, 136–139 social skills, 38 Secondary substance abuse, 242–243 treatment strategies, 243–247 Self-talk strategy, 88–89 Severe and persistent mental illness biological bases, 137 reasons for drug use, skills sheet biological bases, 136–139 interaction of drugs/alcohol and severe and persistent mental illness, 140–142 substance abuse impact on symptoms, 128 substance abuse treatment, 4–5 difficulties of, 6–7 traditional service models, Shaping, 39 Skills, 37–38 learnable, 38 Skills sheet alternative ways to cope, 195–197 anger management, 216–217 assertiveness training, 214–215 avoidance coping, 148–149 biological bases of mental illness, 136–139 boredom, 186–187 coping with symptoms of severe and persistent mental illness/ medication side effects, 192–194, 195–197 cravings, 143–145 depression, 188–191 distraction, 195–197 drug refusal skills, 115–117, 150–151 offering alternative, 118–120 request person stop asking, 121–122 talking to drug dealer, 123–124 talking to stranger, 123–124 employment skills, 218–220 escape coping, 150–151 habits, 143–145 hepatitis prevention, 161–164 high-risk situations, 143–145 other substance use, 183–185 HIV prevention definitions, 152–154 demonstrating condom use, 155–158 practice role-playing, 159–160 reducing risk, 155–158 268 Index risky behaviors, 152–154 transmission, 152–154 job interview preparation, 218–220 job training, 218–220 lapses, 180–182 making plans with friend, 113–114 money management, 202–206 motivation, 198–201 partner using drugs, 210–211 positive and negative aspects of using, 134–135 relapse prevention and problem solving high-risk situations, 178–179 review of drug refusal and coping skills, 175–177 relaxation training, 221–222 schizophrenia, biological bases, 136–139 severe and persistent mental illness biological bases, 136–139 interaction of drugs/alcohol and severe and persistent mental illness, 140–142 small talk, 111–112 social skills, 109–110 creating drug-free social network, 212–213 stress, 188–191 substance use, 134–135 interaction of drugs/alcohol and severe and persistent mental illness, 140–142 talking to someone, 195–197 talking to your doctor, 192–194 triggers, 143–145 victimization, 207–209 violence, 207–209 Skills training leader training, 28–29 teaching vs group psychotherapy, 28 Small talk skills sheet, 111–112 social skills training, 97–98 Social cognition, 37 Social dysfunction, 37 circumstances, 38 Social impairment, 6–7 Social learning theory, 38–40 modeling, 39 overlearning, 39–40 reinforcement, 39 shaping, 39 Social perception, 37 Social problem solving, 37 Social skills model, 37 component skills, 37 generalization, 40 Social skills training, 22–23, 27, 28, 37–47 coaching, 43 describing steps of skill, 41–42, 42 drug refusal skills, 102–105 drug dealers, 103 friends/family, 103 procedures, 102–103 rationale, 102–103 refusing and leaving situation, 104 refusing and requesting not to ask to use drugs anymore, 104 tailoring skills to different clients, 104–105 empirical support, 46 feedback, 101–102 general, 96–102 group members in role-play, 42–43 group members introduction, 97 group structure, 45–46 homework, 45 low functioning and symptomatic clients, 106–107 making plans with friend, 98–100 modeling skill in role-play, 42 positive feedback, 43–44 procedures, 38–45 prompting, 43 rationale, 41, 96–97 refusal skills, 100–101 repeated role-play, 44–45 schizophrenia, 38 skills sheet, 109–110 creating drug-free social network, 212–213 small talk, 97–98 steps, 40–45, 41 structure, 96–97 Stress relapse prevention and problem solving, 171 skills sheet, 188–191 Substance abuse, seealso Drug refusal skills impact on symptoms, 128 need for more intensive drug treatment, 249 pros and cons, 127 skills sheet, interaction of drugs/alcohol and severe and persistent mental illness, 140–142 types, victimization, 207–209 violence, 207–209 Supportive Treatment for Addiction Recovery (STAR), BTSAS, results compared, 9–10 T Team approach, 31 Termination, 27–28 difficulty leaving BTSAS, 224 goal setting, 228–229 informing clients of their progress, 223–224 issues, 223–224 from mental health treatment due to continued drug use, 248–249 most useful coping strategies identification, 227–228 open enrollment, 224 review of progress, 225–227 sessions, 225–230 treatment referral, 229–230 Therapist–client collaboration, 15 Therapists, role in group, 31–32 Time frame, 27–28 Transtheoretical Model of Change, 16–17 Treatment biases, 15–16 Treatment environment, positive, supportive, and reinforcing, 14–16 Treatment participation obstacles, helping clients overcome, 16–18 Triggers, skills sheet, 143–145 U Urinalysis contingency procedures, 21–22, 26 conducting, 85 documenting self-report of use, 85 financial reinforcement, 83, 84–85 goal drug selection, 84 negative test, 85–86 positive test, 86–90 providing immediate feedback, 85–86 social aspect, 83 urinalysis test, 85 V Victimization skills sheet, 207–209 substance abuse, 207–209 Violence skills sheet, 207–209 substance abuse, 207–209 Index 269 .. .Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness. .. consumers with serious mental illness; hence, the current title: Behavioral Treatment for Substance Abuse by People with Serious and Persistent Mental Illness: A Handbook for Mental Health Professionals... alcohol treatment literature and a rigorous rating system for different treatment strategies 18 Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness Several