Dual Disorders: Counseling Clients With Chemical Dependency and Mental Illness

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Dual Disorders : Counseling Clients With Chemical Dependency and Mental Illness Daley, Dennis C.; Moss, Howard.; Campbell, Frances. Hazelden Publishing 0894864491 9780894864490 9780585156231 English Alcoholics--Mental health, Alcoholics--Counseling of, Mentally ill--Alcohol use, Mentally ill-Counseling of, Substance abuse--Patients--Mental health, Substance abuse--Patients-Counseling of. 1987 RC565.D35 1987eb 616.86 Alcoholics--Mental health, Alcoholics--Counseling of, Mentally ill--Alcohol use, Mentally ill-Counseling of, Substance abuse--Patients--Mental health, Substance abuse--Patients-Counseling of.

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DUAL DISORDERS

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About the authors Dennis C. Daley, Ph.D., is director of the Center for Psychiatric and Chemical Dependency Services, Western Psychiatric Institute and Clinic (WPIC), University of Pittsburgh Medical Center, in Pittsburgh, Pennsylvania. He is also an assistant professor of psychiatry in the department of psychiatry and is involved in a research project studying treatments for cocaine addiction. Daley has been involved in starting several dual disorders treatment programs and has written many books, consumer and family recovery guides, and educational videos on dual disorders, addiction, relapse prevention, and family recovery. He lectures frequently throughout the United States and Canada on these topics. Howard B. Moss, M.D., a psychiatrist specializing in alcohol and drug abuse disorders, is an associate professor of psychiatry at the University of Pittsburgh Medical Center. Moss previously directed several chemical dependency and dual disorders treatment programs and is currently involved in several research projects studying vulnerability to substance abuse and a variety of other issues. Moss has written many book chapters and scientific papers on substance abuse and psychiatric disorders. He lectures throughout the United States and Canada on dual disorders and areas related to his research endeavors. Frances Campbell, M.S.N., is a clinical nurse specialist and coordinator of the outpatient component of the Center for Psychiatric and Chemical Dependency Services at WPIC. Campbell has also helped to develop an inpatient program for dual disorders. She is active in teaching and research in addition to clinical care. Campbell has published several papers, book chapters, and recovery guides on addiction and dual disorders and has presented lectures and workshops throughout the United States on dual disorders.

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DUAL DISORDERS Counseling Clients With Chemical Dependency And Mental Illness Second Edition Dennis C. Daley Howard Moss Frances Campbell

HAZELDEN® INFORMATION & EDUCATIONAL SERVICES

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Hazelden Center City, Minnesota 55012-0176 © 1987, 1993 by Hazelden Foundation All rights reserved. Published 1987. Second Edition 1993 Printed in the United States of America. No portion of this publication may be reproduced in any manner without the written permission of the publisher Library of Congress Cataloging in Publication Data Daley, Dennis C. Dual disorders: Counseling clients with chemical dependency and mental illness/Dennis C. Daley, Howard Moss, Frances Campbell-second edition. p. cm. Includes bibliographical references and index. ISBN 0-89486-449-1 1. Dual diagnosisPatientsCounseling of. I. Title. [DNLM: 1. Alcoholismcomplications. 2. Counseling. 3. Mental Disorderscomplications. WM 274 D139d RC564.68.D35 1993 616.86'065 1dc20 DN LM/DLC for library of Congress 92-48321 CIP All quotes and personal stories found in this book's anecdotes and examples reflect the actual experiences of these men and women. All names and identifying details have been changed in order to protect the subjects' anonymity. In some instances, the experiences of several people have been pulled together to form composite case studies.

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Contents Preface to the Second Edition

ix

Chapter OneDual Disorders: An Overview

1

Introduction

1

Prevalence of Dual Disorders

2

Three Perspectives on Dual Disorders: Patient, Family, Counselor

8

Systems Issues in the Treatment of Dual Disorders

15

Summary

16

Chapter TwoChemical Dependency and Recovery

19

Assessing Chemical Dependency

19

Treatment Issues for Chemical Dependency

26

Areas of Emphasis in Recovery from Chemical Dependency

28

Family Involvement

33

Summary

35

Chapter ThreePersonality Disorders and Chemical Dependency

37

An Overview

37

Classification of Personality Disorders

38

Types of Personality Disorders

40

Summary

43

Chapter FourAntisocial Personality Disorder and Chemical Dependency

45

An Overview

45

Assessment Criteria

48

Assessment Issues

50

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Counseling Issues

51

Summary

59

Chapter FiveBorderline Personality Disorder and Chemical Dependency

61

An Overview

61

Characteristics of BPD

62

Assessment Criteria

66

Assessment Issues

67

Counseling Issues

68

Medication Issues

73

Summary

74

Chapter SixDepression and Chemical Dependency

77

An Overview

77

Major Depression

79

Assessment Criteria

81

Assessment Issues

82

Counseling Issues

82

Dysthymia

100

Assessment Criteria

100

Assessment Issues

101

Counseling Issues

101

Assessment of Suicidal Risk

102

Summary

104

Chapter SevenBipolar Disorder and Chemical Dependency

107

An Overview

107

Characteristics and Effects of Bipolar Disorders

109

Assessment Criteria

112

Assessment Issues

113

Counseling Issues

114

The Continuum of Care

122

Summary

124

Chapter EightAnxiety Disorders and Chemical Dependency

127

An Overview

127

Panic Disorder

128

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Assessment Criteria

131

Assessment Issues

132

Counseling Issues

133

Phobic Disorders Counseling Issues

136 137

Obsessive-Compulsive Disorder

138

Posttraumatic Stress Disorder

139

Assessment Criteria

141

Assessment Issues

142

Counseling Issues

143

Generalized Anxiety Disorder

145

Assessment Criteria

147

Assessment Issues

147

Medication Issues

148

Counseling Issues

148

Outpatient Aftercare

148

Summary

150

Chapter NineSchizophrenia and Chemical Dependency

151

An Overview

151

Characteristics of Schizophrenia

152

Assessment Criteria

157

Staff Issues

158

Assessment Issues

159

Detoxification

161

Treatment Issues and Services

161

Summary

169

Chapter TenOrganic Mental Disorders and Chemical Dependency

171

An Overview

171

Organic Disorders

171

Amnesias

173

Assessment Criteria The Dementias

175 176

Assessment Criteria

176

Assessment Issues

177

Counseling Issues

179

Summary

180

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Chapter ElevenRelapse Prevention and Dual Disorders

181

An Overview

181

Key Clinical Issues in Relapse Prevention

185

Summary

196

Chapter TwelveIssues in Dual Disorders Program Development

197

Introduction

197

Program Proposal

200

Sample Program 1: Inpatient Dual Disorders Unit

203

Sample Program 2: An Outpatient Program for Individuals With Schizophrenia and Chemical Dependency

211

Appendix: Resources for Clients and Families

213

Endnotes

215

Index

233

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Preface to the Second Edition Much has happened in the past several years in the area of dual disorders. A significant body of professional and self-help literature has emerged, including numerous specialized papers, books, and journals that address some of the issues confronting individuals with dual disorders. Both professional and recovery literature is beginning to address subpopulations, such as those with mood disorders and chemical dependency, anxiety disorders and chemical dependency, and so on. The fact that the first edition of this book sold well over thirty thousand copies suggests that clinicians see dual disorders as a significant area in which to increase their knowledge and skill. We were very pleased with the positive response the first edition received from many clinicians in all types of clinical programs, from state hospitals for the chronically mentally ill to outpatient drug and alcohol clinics. It was clear from the feedback that practical information about dual diagnosis patients and their families is needed. Fortunately, clinicians now have access to recovery-oriented materials for clients with dual disorders and for their families, in addition to professional literature. Hazelden Educational Materials, for example, has responded to the growing need for recovery-oriented information by developing a publishing program specifically for dual diagnosis consumers and their families, and even for specific subgroups of dual diagnosis consumers. More self-help groups are now available to individuals with dual disorders. These groups are known by a variety of names and acronyms, such as Double Trouble, CAMI, SAMI, MICA, MISA, STEMSS, and so on. Many clients benefit from such specialized self-help peer-support programs because they offer help for psychiatric as well as chemical dependency disorders. Professional training has increased significantly as well. Many workshops, seminars, and conferences are addressing dual disorders. As we

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speak at agencies or conferences on this topic in the United States and Canada, we find that the participants represent a good balance of professionals in the chemical dependency and the mental health fields. This shows that both fields have a strong interest in this topic and a need for more information. The fields of mental health and chemical dependency each address different aspects of dual disorders, since the clinical population is quite heterogeneous. Recently, for example, much emphasis has been placed on helping a subgroup of dual-diagnosed clients who have persistent mental illness, such as schizophrenia or a recurrent affective disorder, in addition to chemical dependency. We expect that the fields will continue to evolve and improve, particularly since there appears to be much sharing of expertise and knowledge between the mental health and chemical dependency fields. Although we have come far in the past half-dozen years, we still need to improve our existing services and develop new treatment approaches for diverse groups of patients. We need to expand research endeavors to help determine the best treatments for various types of dual diagnosis patients, particularly since the field deals with constantly changing clinical populations. In our programs, for example, we have seen a significant increase in patients with crack cocaine addiction and psychiatric disorders. Although current treatment approaches help many of these patients, it is clear that new approaches are needed to increase the retention of clients in treatment and decrease relapse rates for this subgroup. The second edition of Dual Disorders: Counseling Clients with Chemical Dependency and Mental Illness is based on our review of research, clinical, and self-help literature, as well as on our continued involvement in treating patients with dual disorders.* Since the publication of the first edition, we have been involved in developing a number of inpatient and outpatient programs for dual-disordered patients and their families. We have learned much from this experience and feel that it has helped us improve on the first edition. The revised edition differs from the first in several ways. We have expanded the information in the chapters on specific psychiatric disorders *We use the American Psychiatric Association's DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised [Washington, D.C.: American Psychiatric Association, 1987]) criteria for disorders. The reader should keep in mind that diagnostic criteria may change in the future when DSMI-IV is published. It is important to keep abreast of such changes.

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and chemical dependency. New chapters have also been added on relapse and issues in developing dual diagnosis programs and services for patients and families. The reader will also find that the bibliography at the end of the book spans a broad range of literature so that a specific disorder or topic can be studied in more depth. While the first edition focused more on comorbid alcoholism and psychiatric disorders, the revised edition discusses other chemical dependencies as well. Despite the book's expansion and improvement, it has several limitations that we wish to point out. First, there is still little research on treatment approaches specific to dual diagnosis patients. We assume that, in general, an integration of psychosocial, pharmacologic, and self-help interventions is the best way to approach dual-diagnosed patients. The field has a long way to go toward matching patients to the best treatments available. Research has yet to determine the best psychosocial treatments, for example, for specific combinations of dual disorders. Second, this book is intended to be a practical aid to mental health and chemical dependency counselors, and as such, it does not explore the etiology of disorders or discuss theoretical issues. We focus on educational, cognitive, and behavioral interventions that readers can use in their daily work with dual-disordered patients and their families. Third, this book provides an overview of some of the more common disorders associated with chemical dependency: it does not address all disorders, such as multiple personality disorder or dependent personality disorder. It also does not separately address the many complexities involved in cases in which multiple Axis 1 and Axis 2 disorders coexist with chemical dependency. For example, some patients have four diagnoses: an anxiety disorder, a mood disorder, a personality disorder, and a chemical dependency. These ''multiple disorders'' patients are, as you might expect, often more difficult to treat than those with "dual disorders." Fourth, some of the treatment issues and needs of special populations are not addressed in great detail. These include clinical populations such as the homeless, patients who are HIV-positive or have AIDS, gay and lesbian patients, women, African Americans, and American Indians. An overview book like this simply has no room to go into as much depth as we might wish. Fifth, although we discuss the family's role in assessment, treatment, and recovery, the area needs more attention. While quite a bit of new literature has been published on dual disorders from the patient's perspective,

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relatively little attention has been paid to the perspective of the family. This is a distinct area that needs more attention from researchers, clinicians, and self-help programs, since families often experience a significant burden and often have recovery issues and needs of their own. Despite the limitations of this book, this revised edition will provide mental health and chemical dependency counselors with more ideas on how they can better serve the growing population of dual-diagnosed patients. We encourage our colleagues to continue developing research projects and clinical programs, and to continue sharing their expertise. Special thanks to Tim Mclndoo at Hazelden Educational Materials for his editorial help and the support he provided throughout the revision of this book. We also wish to thank Ron Schaumburg for his fine editing job and Maureen Meyer for her excellent editorial work on this book. Both Ron and Maureen made this book more user-friendly.

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Chapter 1 Dual Disorders: An Overview Introduction One of the toughest challenges you will face as a mental health professional is treating people who suffer from dual disorders. The term or dual disorders,dual diagnoses, refers to cases in which the individual has both a chemical dependency disorder and another serious psychiatric illness, such as depression. The symptoms of one condition may mask the symptoms of the other or even make them worse. In fact, the use of the word dual may be misleading, since it is possible for a person to have three or more concurrent conditions, each requiring its own approach to treatment. If you are alert to the complex nature of this difficult condition, you have a better chance of guiding the patient to recovery. For some people with dual disorders, the substance abuse problem dominates the clinical picture. These individuals usually enter the health care system through a chemical dependency program. Unless the dual nature of their problem is known, however, they may find that even after becoming sober, their mood remains low or their feelings of anxiety persist. For others, the psychiatric disorder takes priority, so they seek help through a mental health clinic or hospital. Treatment combining counseling and medications may improve their mood or relieve their anxiety, but until the chemical dependency issue is addressed, their compulsion to abuse substances will remain. Therapy must recognize and address both conditions, or the risk of relapse remains high. People with dual disorders vary greatly in all measurable ways: number and types of diagnoses, severity of substance abuse and extent of psychiatric impairment, the number and types of psychosocial problems, availability of social support systems, levels of motivation, and personal strengths. It is also possible to distinguish several subgroups among people with dual disorders:

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· Those with a primary mental illness who also meet criteria for chemical dependency or whose occasional use of alcohol or drugs causes problems serious enough to warrant treatment. This group includes clients who have recurrent or chronic forms of mental illness as well as those who experience one or two acute episodes. ·

Those with a primary chemical dependency who experience psychiatric problems.

· Those whose histories are so complex that it is difficult to determine which diagnosis is the primary one. Members of this group often exhibit severe problems caused or exacerbated by either of their disorders. On one end of the dual disorders spectrum are those individuals who accept the reality of their condition, who are internally motivated to change, who function relatively well, and who respond to treatment. On the other end are the persistently and chronically ill people who may refuse to admit they have a problem, who are not motivated to change, who resist others' efforts to help them, and who therefore respond poorly to treatment. Such people generally enter the health care system only under outside pressure from external forces: loved ones, employers, the legal system, or involuntary commitment to psychiatric care. As a treatment professional, you must be prepared to deal with clients from both ends of this spectrum. Prevalence of Dual Disorders An informal survey among our colleagues who work with the chronic and persistently mentally ill suggests that between 40 percent and 75 percent of their clients have a drug or alcohol problem that complicates the process of recovery from the psychiatric disorder. The authors' combined years of personal experience with many patients suggest that this assessment is accurate. For those readers who require a more scientific basis for such a conclusion, strong empirical evidence confirms that the problem of dual disorders is widespread. The Alcohol, Drug Abuse, and Mental Health Administration estimates that at least 50 percent of the 1.5 million to 2 million Americans with severe mental illness also abuse alcohol or illicit drugs. 1 Other studies reach similar conclusions. National Institute of Mental Health Survey The National Institute of Mental Health (NIMH) published results of

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the Epidemiologic Catchment Area (ECA) survey of more than twenty thousand adults in five communities within the United States. 2 The survey found current or lifetime prevalence of psychiatric disorders, including substance abuse disorders, to be as follows: 13.8% 12.6% 6.2% 5.1% 2.5% 2.5% 1.5% 1.5% 1.1% 1.0% 0.4% 0.1% 0.1%

alcoholism (alcohol abuse or dependence) phobias drug abuse or dependence major depression obsessive-compulsive disorder antisocial personality disorder dysthymic disorder panic disorder cognitive dysfunction schizophrenia mania (bipolar disorder) somatization disorder anorexia

As this list shows, two of the top three diagnoses involve substance abuse of some kind. Overall, 34 percent of the population had experienced a form of mental illness or chemical dependency at some time in their lives. While 22.5 percent of those responding claimed a history of psychiatric problems, 16.4 percent had a substance abuse disorder. Such findings indicate that a significant number of those surveyed had two or more conditions. Further statistical breakdown reveals the true extent of this overlap: 29 percent of the people with a psychiatric illnessnearly three out of ten in this grouphave been diagnosed as also having a substance abuse disorder at some time in their lives. Some other findings from the ECA survey: ·

37 percent of the alcoholics met criteria for a mental disorder other than drug abuse or dependence.

·

53 percent of people with a drug abuse or dependence disorder had at least one other psychiatric diagnosis.

·

64 percent of drug abusers currently in treatment met the criteria for a coexisting mental disorder.

On the whole, such numbers show that rates of concurrent mental disorders

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are very high among both alcoholics and drug abusers. The survey also found that compared with the general population, the rates of every psychiatric or drug abuse disorder were higher among alcoholics. The odds are nearly three to one that an alcoholic or a drug abuser will meet lifetime criteria for another psychiatric or drug abuse or dependence disorder. 3 Among those reporting a history of substance abuse, the most prevalent psychiatric disorders are antisocial personality disorder (83.6 percent), bipolar disorder (60 percent), and schizophrenic disorders (47 percent).4 In other words, if you are dealing with a person who has an antisocial personality disorder, the chances are better than eight out of ten that such an individual also has some kind of problem with alcohol or drugs. Studies of Clinical Populations Other studies have reached similar conclusions.5 M. Hesselbrock and colleagues studied 331 hospitalized alcoholics in several treatment settings and found that 77 percent of the total cohort met criteria for another substance abuse or psychiatric disorder. The lifetime rate of depression among alcoholics was 52 percent for women and 32 percent for men. Among male alcoholics, personality disorders were the most common psychiatric diagnosis; 49 percent met criteria for one of these disorders. Rates of anxiety, bipolar, and schizophrenic disorders were similarly high.6 Ross, Glaser, and Germanson found that out of 501 drug abusers, 78 percent met NIMH Diagnostic Interview Schedule (DIS) criteria for a psychiatric disorder during their lifetime, and 65 percent currently met criteria for a disorder. The most common disorders were antisocial personality disorder (47 percent lifetime, 36.5 percent current); anxiety disorders, excluding generalized anxiety disorders (39 percent lifetime, 33 percent current); psychosexual dysfunctions (34.5 percent lifetime, 6.4 percent current); and affective disorders (34 percent lifetime, 27 percent current). This study found that patients who abused both alcohol and other drugs were the most psychiatrically impaired: 95 percent of these polysubstance abuse patients met criteria for at least one other psychiatric disorder. The mean number of lifetime DIS diagnoses per patient in this study was almost 5, and the mean number of current diagnoses per patient was 3.5.7 During a 1990 professional meeting focusing on young adult chronic patients, many of whom had dual disorders, Warner reported results of a study in which 70 percent of seventy-nine randomly selected young adult

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chronic clients were found to have moderate or severe substance abuse problems. He noted that after these individuals were provided with intensive case management services, this percentage was cut almost in half. Other presenters at this same meeting reported that people with dual disorders have higher rates of arrest, murder, and suicide. 8 One of the authors of this book (Daley) and two colleagues reviewed the cases of 192 patients participating in an inpatient dual disorders program at the Western Psychiatric Institute and Clinic in Pittsburgh. They found that on average, and excluding substance withdrawal or intoxication diagnoses, each of the patients had nearly three current diagnoses. The most common psychiatric diagnoses among this group were personality disorders (i.e., borderline, antisocial, and mixed) and affective disorders.9 Salloum and two of the present coauthors (Daley and Moss) reviewed literature on substance abuse and schizophrenic disorders and found that approximately 38 percent of individuals with schizophrenia also had a comorbid substance abuse disorder.10 Layne reports an even stronger correlation: in his review, he found that studies show between 45 percent and 74 percent of individuals with schizophrenia also had a substance abuse problem.11 Goodwin and Jamison recently summarized results of twenty studies of individuals with affective disorders who also had problems with alcohol abuse. More than half of these studies reported alcoholism rates of at least 25 percent among patients with affective disorders; the range was from 11 percent to 75 percent.12 These rates did not include drug abuse or addiction; had they done so, the reported rates of dual disorders would no doubt have been even higher. Like many scientific studies, the ones cited here may contain undetected methodological flaws. For example, in some chemically dependent individuals, depressive symptoms result primarily from the effects of alcohol or drugs on the central nervous system. These illnesses, more properly labeled organic affective disorders, are categorically different from major depressive illness. Most substance-induced depressions remit within a few weeks following abstinence. Therefore, if the subjects in these studies were evaluated before they had been substance-free for a sufficient period of time, the prevalence of dual diagnosis would appear inflated. Even taking the risk of such methodological flaws into account, however, there is substantial empirical evidence to indicate that many individuals have both a chemical dependency and a psychiatric disorder.

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Possible Relationships Between Chemical Dependencies and Psychiatric Illnesses Many caregivers who work with dual-disordered clients are often distracted by the "chicken or the egg" questionthat is, did the chemical dependency come first, or did the psychiatric disorder? Practically speaking, the question may be irrelevant. There are many possible patterns of interaction between chemical dependency and psychiatric disorders. 13 Sometimes the "chicken" comes first; sometimes it's the "egg''; sometimes they seem to appear simultaneously, rendering cause and effect indistinguishable. The following list discusses the most common patterns. 1. Chemical dependency increases the risk of developing a psychiatric illness. The ECA survey and studies of patients in chemical dependency programs strongly suggest that the odds of a chemically dependent individual having a psychiatric illness are higher than would be expected among the general population. 2. Psychiatric illness increases the risk of developing a chemical dependency. Studies of patients receiving psychiatric care show higher than expected rates of chemical dependency. Rates of substance use disorders are especially high among patients with antisocial personality disorder, bipolar disorder, or schizophrenia. 3. Psychiatric symptoms may affect the onset, duration, or response to treatment of chemical dependency. Cloninger characterized alcoholics into two subgroups, male-limited (25 percent of sample) and milieu-limited (75 percent). Members of the male-limited group appear more likely to be influenced by biological factors and to develop substance abuse problems earlier (usually before age twenty-five) than members of the other group; they are more likely to get into trouble with the law and more likely to have biological fathers who have problems with substance use and antisocial behavior. Members of the milieu-limited group are thought to be more influenced by environmental factors in developing alcoholism, and they develop it at a later age.14 McLellan and colleagues report that patients with higher ratings of psychiatric severity on the Addiction Severity Index are more likely to relapse to substance abuse than other patients are.15 Psychiatric impairment has a strong association with relapse to drug use among opiate addicts.16 Patients who have both chemical dependency and antisocial personality disorder drop out from treatment at a higher rate, and thus have a poorer prognosis than other diagnostic groups do. Similarly, Rounsaville and colleagues found that alcoholics who also have

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one or more psychiatric diagnoses have a poorer treatment outcome than do patients without a psychiatric diagnosis. 17 As we'll show in chapter 6, however, the dual diagnosis of depression and chemical dependency appears to have a comparatively good prognosis. 4. Psychiatric symptoms may arise as a direct result of chronic substance abuse or withdrawal. Drugs and alcohol may directly impair mood or cognitive functioning. Depression, mania, anxiety, panic, paranoia, delusions, and hallucinations are some of the specific symptoms that may result from chronic use of substances or as part of an acute or protracted withdrawal syndrome. For example, users of PCP, hallucinogens, or stimulants may become psychotic and present a clinical picture that resembles schizophrenia. Alcoholics and cocaine addicts may experience depression and suicidality during withdrawal. Individuals who abuse tranquilizers may show agitation and anxiety symptoms when they cut back or stop using these substances. The preceding examples generally involve chronic or heavy substance abuse. Keep in mind, however, that even small doses of alcohol or other drugs can cause difficulty in the patient who has a chronic or persistent mental illness. 5. Symptoms of psychiatric illness may result as the indirect consequences of chemical dependency. Many individuals suffer tremendous personal consequences as a result of their chemical dependency. Disturbed family and interpersonal relationships, increased health problems, trouble on the job, loss of dignity, and squandered potential are common among the chemically dependent. Use of illicit drugs can lead to trouble with the legal system, resulting in loss of freedom as well. Any of these circumstances can contribute to depression. Chemical dependency can also produce antisocial behavior such as selling drugs, stealing to support an addiction, or aggressiveness toward others as a result of impaired judgment. 6. Over time, symptoms of chemical dependency and psychiatric illness may become linked or interrelated. In some cases, it may be difficult to distinguish which disorder is primary and which is secondary. Many of those with chronic disorders come to treatment with a very complex set of symptoms and problems. The specific symptoms may even vary from one episode of an illness to another. 7. The dual disorders can develop independently at different times. Alcoholics who have been sober for a year, or drug addicts who have been clean for many months, can still develop an episode of major depressive illness. Individuals with schizophrenia or panic disorder may become dependent on alcohol or other drugs while their psychiatric symptoms are in remission.

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It is not always easy to determine if dual diagnoses are present, because a psychiatric disorder can mask chemical dependency, and chemical dependency can mask a psychiatric disorder. Even after you have established the two diagnoses, it may not be clear which problem should be treated first. Some experts believe the psychiatric illness takes precedence, while others believe the chemical dependency should have priority. Depending on circumstances, either position may be correct. In any case, treatment must address both conditions at some point, either sequentially or simultaneously. Untreated chemical dependency may contribute to a relapse of the psychiatric disorder, and untreated psychiatric disorders may contribute to an alcohol or drug relapse. Three Perspectives on Dual Disorders: Patient, Family, Counselor Patient A single psychiatric illness can be trouble enough. People with dual disorders, however, are in a kind of double bind. Certain subgroups, such as the chronically mentally ill, often have tremendous difficulty in daily functioning. They may be unable to find or keep a job, live independently, or develop satisfying interpersonal relationships. Many have trouble complying with treatment and are at constant risk of relapse. Sicker patients with more symptoms need more care, but unfortunately, they are less likely to remain in treatment. Some people with dual disorders get caught up in a vicious cycle. They enter either the mental health or the chemical dependency treatment system (or both). Then, because these patients are the most difficult to treat, they may provoke negative reactionsanger, frustration, and hopelessnessfrom professionals. Those who have trouble remaining abstinent from alcohol or other drugs may be discharged from treatment even if they exhibit serious psychiatric problems. They get sicker until finally they seek (or are forced to seek) help. They enter the treatment system again, where they experience the same cycle of failure and frustration. Family Psychiatric illness, chemical dependency, or the combination of the two can create a significant burden for the family. 18 The extent of the impact depends on a number of factors, including the severity of the disorders, the length of time over which the family has been exposed to the disorders, the

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behaviors of the dual-disordered member, the relationships between family members and the dual-disordered individual, and the family members' perceptions of and feelings about the situation. For a child living with both parents, one of whom is dual-disordered, there is an additional factor to consider. The absence or unavailability of the parent with dual disorders places a tremendous burden on the other parent. The child's well-being will depend in large measure on the ability of the other parent to function and to maintain the family. Dual disorders can affect virtually any area of family functioning, including the mood and atmosphere in the home, roles assumed by family members, rules by which the family operates, relationships and communication among members, cohesion, and the ability to confront and solve problems. An ill member with serious psychopathology may display violence, poor judgment, psychotic episodes, and severe mood disturbance. He or she may exhaust the family's financial resources or experience multiple addiction or psychiatric relapses. As a result, the family may feel tired, burned out, and hopeless. By the same token, family members can also affect the person with dual disorders for better or worse. For instance, the presence in the home of another person with a psychiatric or a chemical dependency disorder, or both, makes treatment more difficult. Such families have fewer resources, including energy and money, to invest in supporting the process of recovery. As a counselor, you need to be sensitive to such issues. Be aware that some families may have had frustrating experiences with treatment systems and thus may mistrust professionals. This can happen when, for example, a counselor who has failed to engage the family in treatment erroneously brands the family as ''resistant." Similarly, some caregivers who focus on pathology are too quick to assume that such families are "dysfunctional" or "codependent," that all members are sick and in need of treatment. Be cautious about applying such judgmental labels to families. Try to appreciate the fact that many families and individual members exhibit tremendous resourcefulness and resilience in dealing with their troubled relatives. In many cases, these families have learned how to survive and cope well with an extremely difficult situation. In your assessment, look not only at the family's problem areas but at its strengths as well. You will need to build on those strengths in the weeks and months ahead. You will best serve your clients if you consider the following concerns and issues common to many families struggling to help a dual-disordered member:

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·

Causes of the illnesses

·

Feelings of guilt or responsibility for causing the disorders

·

Fears about safety for the family or the ill member

·

Worries that other family members may become mentally ill or chemically dependent

·

Degree of responsibility families must take for treatment

·

The other family members' needs for treatment and participation in support groups

·

Strategies the family can use to motivate the identified patient when he or she resists treatment or fails to comply

·

Treatment effectiveness and long-term outcome

·

Effectiveness of medications

·

Causes of relapse of the psychiatric illness and how to deal with it

·

Causes of relapse of the chemical dependency and how to deal with it

·

Handling suicidal threats or behaviors

·

Coping with persistent symptoms of mental illness

·

The need to hospitalize the family member

·

Possible repercussions of involuntary hospitalization

·

Managing the emotional and financial burden

· Impact of the illness on any children who may be involved: what to tell them about the situation, and how to help them deal with their feelings and reactions ·

Setting behavioral limits on the dual-disordered member

·

Need for changes in the family's behavioral patterns, such as abstaining from alcohol in the person's presence

Counselor Theoretically, mental health counselors are more experienced in treating clients with psychiatric problems, while chemical dependency counselors are more accustomed to treating alcoholics and drug addicts. In practice, though, there is a considerable degree of overlap. Both groups of professionals work with clients who have dual disorders. They often discover that their usual approaches to treatment are not always adequate. chemical dependency counselors must learn to recognize psychiatric disorders and to deal with them in an appropriate and timely manner throughout the continuum of carein detoxification, rehabilitation, outpatient,

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and aftercare programs. Similarly, mental health counselors need to recognize and deal with clients who have a chemical dependency problem, and they must be prepared to offer the full range of treatment options, including support groups and Twelve Step programs. For these reasons, you will need to be ready to carry out many different functions in the course of your client's treatment: assessment, treatment, referral, and advocacy. You should be aware of all the resources available in your community: treatment centers, self-help groups and their locations, social and case management, economic assistance, housing, vocational training, and so on. Since psychiatric hospitalization may be needed with some dual-disordered patients, familiarize yourself with the procedures and community standards for voluntary and involuntary hospitalization. You should also have a working knowledge of planned intervention, which is a common strategy for influencing chemically dependent individuals to seek treatment. 19 Another important point: Be aware of your own limitations. Do not attempt to provide treatment to patients if you lack knowledge of or experience with their disorders. For more seriously impaired clients, establish goals that are realistic and achievable. You may have to modify your view of what constitutes success or failure in cases involving patients whose dual disorders significantly impair their judgment and functioning. Your attitudes and perceptions are critical influences on the process and outcome of clinical interventions. Some mental health professionals, for example, tend to regard patients with substance use disorders less sympathetically than those with psychiatric illness. Similarly, some chemical dependency professionals are skeptical about the impact (or even the reality) of certain psychiatric illnesses; they may tend to assume that all of their clients' problems stem simply from chemical dependency. Like their mental health counterparts, they may judge or perceive negatively patients who have certain disorders. For example, when confronted with a person who has been diagnosed as having borderline or antisocial personality disorder, the caregiver may label the patient as "problematic" before treatment has even started or before it has been given a fair chance to work. Understandably, perhaps, some clinicians look unfavorably on patients who relapse to substance abuse during treatment or shortly afterward. They tend to judge less harshly those patients who show symptoms of their psychiatric illnesses after a period of remission. Such attitudes and perceptions may affect your involvement in the treatment process or lead to undue pessimism about its potential results.

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If you are a chemical dependency professional, you may need to reexamine your philosophy and attitudes concerning the use of medications. It is a fact that for many individuals with certain psychiatric disorders, medications are a necessary and effective therapeutic option. Do not assume, as some counselors do, that the need for these medications indicates that the patient is "not really sober or clean" and is "still dependent on drugs." Failure to assess a patient's need for medication and to make appropriate prescriptions available is unethical because it can prolong suffering and interfere with or prevent recovery. An example from our case files illustrates the point: a forty-four-year-old male alcoholic named Ned became severely depressed a few months after achieving sobriety. Although aware of Ned's depression, his counselor in a local chemical dependency program told him that she "did not believe in medications" for alcoholics. For some time, she continued to treat Ned with supportive therapy only. There were some very modest improvements in his symptoms, but overall his depression remained severe. Finally, after suffering for nearly a year, Ned insisted something else be done. Only then did the counselor refer him to us for psychiatric evaluation. We designed a course of treatment that combined antidepressants with psychotherapy. Within a few weeks, Ned reported significant relief in his depressive symptoms. Had the counselor been aware of the potential value of medications, Ned's suffering could have ended much sooner. Such stories, unfortunately, are all too common. Again, by the same token, some mental health professionals may need to evaluate their beliefs and attitudes regarding the value of self-help programs in promoting recovery. Some therapists are saddled with serious misconceptions and erroneous beliefs about what self-help programs do and how they function. Consequently, they either fail to inform patients that these programs are available or they strongly discourage anyone from taking advantage of them. Another example from our clinic makes this point: Stuart, a twenty-eight-year-old drug addict with a long history of multiple psychiatric disorders, told us his previous outpatient therapist had said that Narcotics Anonymous (NA) was a "religious program" and that there was no evidence it was effective in helping addicts stay off drugs. We took the time to correct Stuart's impressions. Certainly NA, like all related Twelve Step programs, has a spiritual component, but this is by no means the same as a "religion." We also told him of reports from tens of thousands of addicts, some of whom were participants in our own treatment program, who believe that their lives may very well have been saved as a

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result of participation in NA. Surely such evidence supports the notion that the NA program can be effective. The healing power of self-help programs is difficult to describe. If you have not already done so, we recommend that you attend two or three open meetings of Alcoholics Anonymous (AA), Cocaine Anonymous (CA), Narcotics Anonymous (NA), or other similar self-help groups to see recovery in action. Witnessing a meeting will give you a clear image of the dynamics of recovery and provide a sense of the powerful effects of the fellowship available in such a setting. Attending meetings broadens your perspective: in clinical situations, you may see only those addicts who are struggling with problems; sitting in on a self-help meeting, you have the opportunity to see some addicts who are doing well. The healing forces at work in self-help programs aimed at drug or alcohol abuse often apply equally well in addressing psychiatric disorders. People can help each other recover by sharing strategies for adjusting to their mental disorders and supporting each other in their efforts to overcome the impact of the disorders on their lives. Many reports indicate that Twelve Step programs such as AA and NA are effective in promoting recovery from alcoholism or drug addiction. 20 Some caregivers tend either to overdiagnose or underdiagnose cases of dual disorders. We caution against both tendencies. For example, getting drunk on alcohol or high on pot does not always and automatically indicate that the person doing so has a substance abuse or substance dependence disorder requiring treatment. Such behavior may represent instead an incident of substance misuse. On the other hand, you are no doubt aware of cases in which alcoholism or drug addiction was clearly present but was not diagnosed. The same problem exists with regard to the psychiatric aspect of dual disorders. In our practice, we have treated patients who clearly met criteria for a major depressive illness or anxiety disorder but who were told by other caregivers that their symptoms were merely the result of substance use, as in this example: Betty, sixty-five years old, had a long history of alcoholism. She also reported symptoms of phobia and panic. Several therapists in a substance abuse clinic had told her that drinking was the cause of these symptoms. She reluctantly agreed to attend an inpatient rehabilitation program, but her phobic symptoms led her to leave after just one day, saying, "I could not stand being closed in." Eventually Betty was referred to our clinic. We consulted with staff members of the rehabilitation program, who told us Betty had left because "she was thirsty." No,

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they said, they had not even considered the possibility that she suffered from some form of psychiatric illness. Since receiving treatment for her anxiety and phobia, Betty has done quite well. She is sober, and her psychiatric symptoms have stabilized. Sometimes therapists or counselors mislabel their patients because they lack complete information about the condition. A patient who has one or two episodes of antisocial behavior may be slapped with a diagnosis of antisocial personality disorder, even when he or she does not meet the stringent criteria for this diagnosis as spelled out in the Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised (DSM-IIIR)*. Such inappropriate or careless labeling only hurts patients. It is difficult, if not impossible, to develop a healthy therapeutic alliance if the counselor prejudges the patient negatively. Professional Enabling Mental health professionals who lack knowledge or skill or who carry negative attitudes and perceptions about certain conditions or patients may directly or indirectly perpetuate or exacerbate a person's chemical dependency or psychiatric illness. This is known as "professional enabling." Such enabling may be passive, such as ignoring a serious mental health or chemical dependency problem, or active, such as giving inappropriate advice or treatment. Specific examples of enabling include the following: 21 1. Failure to gather an accurate and detailed history of alcohol and other drug use, as well as of psychiatric symptoms. 2. Failure to address the chemical dependency or the psychiatric illness in the treatment plan. 3. Waiting for the person with a substance abuse problem to "hit bottom" or to ask for treatment. 4. Assuming that the patient must acknowledge a psychiatric illness in order to benefit from treatment. 5. Giving oversimplified advice, such as telling a substance abuser to stop drug use without suggesting a professional treatment program, a selfhelp recovery program, or both; advising a patient with serious clinical depression or anxiety to attend AA or NA meetings without considering other options such as medication or psychotherapy. *Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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6. Assuming that major or multiple problems must exist before the patient can be considered chemically dependent or psychiatrically ill. As with any type of illness, there is a range in the severity of, and degree of impairment from, chemical dependency or psychiatric illness. 7. Viewing the chemical dependency as merely symptomatic of a psychiatric illness or viewing psychiatric symptoms as merely caused by chemical dependency. 8. Excluding the family from the assessment or treatment processes when their involvement is indicated. 9. Assuming recovery is in motion simply because a patient stops using alcohol or other drugs. 10. Assuming that each of the dual disorders requires treatment by separate clinicians or in separate programs. 11. Taking a rigid stance against the use of medications to treat serious psychiatric illness. Systems Issues in the Treatment of Dual Disorders Effective treatment of dual disorders often involves patients in at least two aspects of health care delivery: the mental health system and the chemical dependency system. Each of these systems is complex in itself; when both are involved, the potential problems expand exponentially. Among the issues that need to be addressed are access to care, frequency of system use, the economics of care delivery reimbursement, and so on. 22 Many patients with dual disorders use both the chemical dependency and the mental health systems at a relatively high rate of frequency. Unfortunately, some get lost in the shuffle as they are referred back and forth among various systems. Many dual-disordered patients, particularly those with longstanding chronic illnesses, are unable to tolerate this constant shuttling. They may have trouble developing solid therapeutic alliances with professional staffs, resulting in an adverse impact on treatment compliance or outcome. Some evidence suggests that treatment of dual disorders is more successful when managed by one team of professionals in one location.23 Dual-disordered patients use a disproportionate number of medical, legal, social, and emergency services. They require considerable staff time from clinicians as well as administrators.24 Sometimes mental health and

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chemical dependency systems find themselves at odds over which should treat a given patient who suffers from dual disorders. Such territorial battles can result in fragmented and inadequate care. A mental health clinic, insisting that a depressed patient with alcoholism get sober first, may refer the individual to a chemical dependency treatment program. That program, however, may have a policy of refusing to admit depressed patients whose depressive symptoms are not under control. Similarly, a psychiatric facility may treat a person with antidepressants and then refer the patient to a substance abuse program, only to find that the program refuses to accept patients using medication, even if the psychiatric symptoms are in remission. The result of these Catch-22 situations could very well be that the patient gets little or no help from either system. Many individuals with dual disorders are chronic patients who are not employed and whose only income is some type of governmental support. These patients are often ineligible for treatment in private programs that accept only patients with insurance coverage or those who can pay out of pocket. This significantly reduces the treatment options available to chronic patients. Also, a subgroup of these patients are homeless and therefore present additional challenges to the health care system. Chemical dependency programs need to have access to psychiatric and psychological consultation as an aid in assessing patients and planning treatment. For the same reasons, mental health systems need access to professionals with expertise in chemical dependency. Both fields have much to offer each other. The best approach to helping patients is a collaborative one. Ideally, therapists in either field should receive crossover training to increase their ability to serve people with dual disorders. Summary The coexistence of chemical dependency disorders with psychiatric disorders is well documented. As a counselor, you need to be alert to the possibility that your clients may be struggling with not one but two or more serious conditions. Your task is to learn how these diagnoses interact and to understand the potential impact of dual disorders from the perspectives of the patient, the family, the professional caregiver, the treatment system, and other community and social service systems. To intervene effectively as a treatment professional, you will need to be informed not just about the various mental health and chemical dependency disorders but about treatment options and resources as well. You

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must be flexible and willing to assume different roles to help clients and their families. Remain sensitive to family issues; families are your allies in supporting the patient's recovery, and family members may have recovery needs and issues of their own. Be aware, too, of any perceptions, attitudes, and beliefs you may hold concerning mental illness and chemical dependency that may have an impact on your ability to deliver appropriate and timely care.

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Chapter 2 Chemical Dependency and Recovery Assessing Chemical Dependency Diagnostic Criteria The definition of chemical dependency used in this book follows the criteria for psychoactive substance abuse and dependence as outlined in the APA's DSM-III-R. According to DSM-III-R, the group of substance use disorders ''deals with symptoms and maladaptive behavioral changes associated with more or less regular use of psychoactive substances that affect the central nervous system. These behavioral changes would be viewed as extremely undesirable in almost all cultures." 1 DSM-III-R's diagnostic criteria for psychoactive substance dependence, which we have adapted slightly here, include at least three of the following symptoms, some of which have persisted for at least one month, or have occurred repeatedly over a longer period of time:2 1. A substance is often taken in larger amounts or over a longer period than the person intended. 2. There is a persistent desire or one or more unsuccessful efforts to cut down or control substance use. 3. A great deal of time is spent in activities necessary to get the substance, taking the substance, or recovering from its effects. 4. The patient experiences frequent intoxication or withdrawal symptoms when he or she is expected to fulfill major role obligations at work, school, or *Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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home, or the patient persists in substance use when it is physically hazardous. 5. Important social, occupational, or recreational activities are given up or reduced because of substance use. 6. The patient continues substance use despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by the use of the substance. 7. The patient develops a marked tolerancethat is, a need for markedly increased amounts of the substance (at least a 50 percent increase) in order to achieve intoxication or desired effector a markedly diminished effect with continued use of the same amount. 8. The patient manifests characteristic withdrawal symptoms related to types of substances used. 9. A substance is often taken to relieve or avoid withdrawal symptoms. 3 These criteria can be applied to abuse of substances of any type, although some symptoms will not be found with particular classes of compounds. Withdrawal symptoms, for example, do not occur with the use of hallucinogens, but people who use these drugs can still meet the criteria for a substance dependence disorder. A diagnosis of psychoactive substance abuse also applies if the individual does not meet the criteria for dependence but still shows a maladaptive pattern of substance use, as indicated by one or both of the following:4 1. The patient continues to use despite knowledge of having a persistent or recurrent social, occupational, psychological, or physical problem that is caused or exacerbated by use of the psychoactive substance. 2. The patient recurrently uses in situations in which use is physically hazardous (e.g., driving while intoxicated). As in cases of substance dependence, the symptoms of substance abuse must have persisted for at least one month or have occurred repeatedly over a longer period of time. Some authorities argue that except for the presence of a withdrawal syndrome, there is little to distinguish between ''substance abuse" and "substance dependence."5 If that is true, then the ongoing recovery needs of both of these diagnostic groups may be very similar, although some chemically dependent individuals may require an initial period of detoxification, while substance abusers may not. In this country, alcohol remains the number one drug of abuse, but abuse of any substance can meet the criteria for a substance use disorder. Other categories of substances include opioids, psychostimulants, depressants

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(sedative-hypnotics, antianxiety or tranquilizing drugs), marijuana (cannabis), hallucinogens, phencyclidine (PCP), inhalants, and volatile or organic solvents. Many individuals use a combination of substances and thus develop patterns of polydrug abuse and dependence. Polysubstance abuse clients are highly prone to psychiatric illness. As we mentioned in chapter 1, the study by Ross and colleagues found that 95 percent of polysubstance abusers also met lifetime criteria for a psychiatric disorder. 6 Assessment Issues Before you can decide on appropriate treatment goals for your clients, it is crucial that you assess their total ability to function. A complete assessment includes a thorough substance use history as well as a review of medical, psychological, family, educational, occupational, legal, spiritual, social, interpersonal, and recreational functioning. In taking the substance use history, be sure to include the following: ·

specific types of substances used (currently and in the past)

·

patterns of use (every day? only on weekends?)

·

amounts used

·

methods of administration (oral, injected, inhaled)

·

drug(s) of preference

·

use of multiple substances

In assessing drug abusers, you will need to find out how your clients are obtaining their drugs (from prescriptions, drug dealers, friends, family, and so on) and how much money they are spending on them. Ask, too, whether they have ever experienced such events as loss of control over drug use (total loss of control or inconsistent control of substance intake), blackouts, and withdrawal symptoms. Find out what medical, emotional, family, social, spiritual, and economic consequences have arisen from substance use. If a client previously took part in a professional treatment or self-help program for chemical dependency, or at some point was able to achieve abstinence without help, find out all you can about the factors that contributed to the current relapse. Using observation and interviews, you will also assess the person's psychological and psychiatric functioning to find out if a mood, anxiety, thought, personality, or other disorder is present. Keep in mind that assessment is an ongoing process. New information will arise as treatment evolves. Be aware of your client's physical appearance, behaviors, and

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interactions with you and others. One caution: avoid spur-of-the-moment subjective evaluations based on intuition or snap judgments. Instead, look for broad patterns appearing over longer periods of time. Base your conclusions on objective facts. In planning treatment, you may find it helpful to discuss your findings with an experienced consultant. Families are often a key part of the treatment plan. You may therefore need to schedule interviews with members of the family or other concerned individuals who can provide additional details or corroborate the patient's statements. Remember to ask whether any other family members also have a chemical dependency or a psychiatric illness, since many of these disorders tend to run in families. These interviews will also help you determine the impact of the client's illnesses on the family. You may be able to use such information as leverage to motivate the person to change. Do not be surprised, however, if at first clients deny or minimize any impact of their substance abuse on their families. This denial may be the result of psychological defense mechanisms such as repression, but blackouts caused by substance abuse may also contribute. We treated an alcoholic patient who had to be hospitalized as a result of a manic episode that rapidly grew worse over a period of a few days until finally he was unable to function. During this time, he frequently became hostile, threatening, and violent. Once stabilized, the client had little recollection of these incidents, including moments when his behavior jeopardized his own safety and that of his wife and children. In this case, our treatment team interviewed the patient with his wife present. Doing so helped him recall what he had done; the impact of that recollection spurred him to accept the need for treatment. Clinical Assessment Aids A number of aids are available to help you assess your clients' conditions and to supplement your interviews and observations. The Addiction Severity Index (ASI), available from the National Institute on Drug Abuse, is a comprehensive clinical and research instrument for evaluating various problems in alcohol- or drug-dependent people seeking treatment. 7 This structured interview can be completed in less than an hour and covers seven key areas: medical condition, employment, drug use, alcohol use, legal history, family relations, and psychiatric condition. The ASI is also useful in evaluating improvement following treatment. While the rating system used on the ASI provides a global evaluation of psychiatric severity, it does not focus on specific diagnoses.

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Another clinical aid used in many chemical dependency and dual diagnosis treatment programs is the Substance Abuse Problem Checklist (SAPC) developed by Dr. Jerry Carroll. Alone or with the help of another person, the client responds to 377 questions covering a range of topics: motivation; health; and psychological, social, occupational, recreational, religious, and legal functioning. 8 This checklist may help you determine if another psychiatric illness coexists with the chemical dependency disorder. A number of specific items on the SAPC relate to mood, suicidality, and personality, as well as interpersonal and cognitive functioning. Some of the other widely used assessment tools include the following:9 ·

Beck Anxiety Inventory

·

Beck Depression Inventory

·

Drug Abuse Screening Test (DAST)

·

Fear Inventory

·

Gunderson Interview for Borderline Personality Disorders

·

Hamilton Anxiety Scale

·

Hamilton Depression Scale

·

MacAndrew subscale of the Minnesota Multiphasic Personality Inventory (MMPI)

·

Michigan Alcoholism Screening Test (MAST)

·

Millon Clinical Multi-Axial Inventory-II

·

Personality Disorder Examination

·

Spielberger State-Trait Anxiety Scale for Anxiety Disorders

·

Structured Clinical Interview for the DSM-III-R (SCID)

·

Substance Use Disorders Diagnostic Schedule

·

Zung Self-Rating Depression Scale

If you are unfamiliar with the use of these instruments, or with psychiatric diagnosis in general, you may want to seek guidance from other professionals and pursue additional training. Use of Laboratory Tests Urine testing for drugs and blood tests for alcoholism have an important place in assessment and ongoing treatment. Both methods have advantages and drawbacks. Urinalysis can help in diagnosing substance use, especially when the relationship between the client's use of chemicals and the presenting

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symptoms is unclear. For example, you may meet a new client who behaves strangely, stares off into space, talks oddly and rapidly, and expresses paranoid thoughts. At first, you may suspect that this person has paranoid schizophrenia. However, if the results of the urine drug screen indicate the presence of high levels of amphetamine or cocaine, then a more accurate diagnosis would be stimulant drug-related paranoid psychotic reaction. Obviously, differentiating between the two disorders is clinically important. Amphetamine or cocaine psychosis requires a short-term treatment approach similar to that used in treating acute paranoid schizophrenia (that is, psychiatric hospitalization and use of antipsychotic medications). In contrast, drug-induced paranoia mandates a very different long-term treatment plan (and has a better prognosis than "pure" schizophrenia). Of course, you should bear in mind the possibility that the client has both paranoid schizophrenia and an amphetamine abuse disorder. Urine testing also plays an important role in monitoring abstinence during rehabilitation and aftercare. Test results can indicate relapse in the recovering client. Some treatment programs routinely conduct random urine tests on clients. In many cases, urinalysis is a requirement of probation or parole. On the downside, urine screens can be difficult to interpret accurately. Negative results, for example, do not necessarily mean the client is drugfree. These so-called false-negative results can occur if the client's level of drug use falls below the threshold of sensitivity for that particular test. A urine test conducted on a client who used crack cocaine five days earlier will probably produce negative results, because cocaine metabolites usually are detectable in the body for only about three days. But urine tests for marijuana frequently require a lower limit of detection and thus may detect marijuana use a week or more after the fact. Another problem in interpreting urine drug screens is the "false-positive" result. A classic example of a false-positive result is represented by the individual who eats a roll sprinkled with poppy seeds. The next day this person gives a urine sample. The test detects a chemical from the poppy seeds that it identifies as an opiate-like substance. Thus results come back indicating that opiates were present. Fortunately, most labs run a second test to confirm the identity of any substances detected. False positives are inconvenient but are generally less commonand less of a problemthan are false negatives. However, you should be aware that marijuana, in particular, may remain in the body for a long time after the individual has stopped using

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the drug, and it is therefore more likely to produce false-positive results. Positive findings of marijuana use have been reported as long as eleven weeks after last use by individuals classified as "heavy users," whose abstinence was carefully supervised. 10 Urine tests that give only positive or negative readouts are therefore of less clinical value than those that detect actual concentrations of THC (the active ingredient in pot). Generally, during periods of abstinence, even heavy users of marijuana should demonstrate a slow decline in THC levels. Tests showing a "spike" of higher THC concentrations suggest that this person is probably using pot again. Assessing alcohol use poses an even greater challenge. Breath analyzers and alcohol blood tests are only useful if the client has had a drink within the past five hours. Streetwise alcoholics are usually smart enough to stay sober on the day of their clinic visits so their drinking will not be detected. Unless your clients have alcohol in their systems at the time of the clinic visit, it can be difficult to determine if alcoholism is associated with their presenting complaints. Researchers have found that levels of a liver enzyme called gammaglutamyl transpeptidase (GGTP) remain elevated for up to two weeks after a heavy bout of drinking. There is a blood test that can detect these levels and therefore help identify the serious alcohol user. Unfortunately, falsepositive and false-negative results also occur with this test as well. One situation in which false positives sometimes arise involves individuals who take medications for seizures. Another source of false-positive results is liver disease not due to alcoholism (that is, resulting from viral hepatitis or gallbladder disease). GGTP is produced in the liver, and any time liver cells die, they spill GGTP into the blood, where it is detected by the test. As for false negatives, a person who drinks small amounts of alcohol may not have GGTP levels high enough above the threshold to register on the test. The search for a reliable biochemical test for alcoholism is an ongoing research priority. As you know, some patients who abuse substances lie about their habits. Some will even try to supply "clean" urine samples they have sneaked in from outside. For this reason, you need to supervise urine collection closely. Sometimes clients become angry and defensive when asked to give urine samples. In our experience, those who become most upset about giving urine samples are the ones more likely to be using substances. If random urine tests are a routine part of your treatment program, you need to inform your clients of the fact and explain the rationale behind the

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intervention. Doing so reduces the likelihood of problems arising later. Whether or not to take random urine samples from a given client is an individual decision based on your treatment philosophy and goals, although many clients ordered by the courts to undergo treatment are required to undergo routine urinalysis. In our experience, such close monitoring actually makes it easier for patients to remain drug-free. You should also be aware that patients will often contest positive lab results. It's true that false positives do occur, but we have found that the overwhelming majority of clients we tested for substance use who showed positive test results were indeed using drugs, as confirmed by further tests or firsthand reports. Use of Consultation Clinicians come from a variety of backgrounds and have different levels of training in mental health and substance abuse treatment. Depending on your area of expertise, you may want to consider consulting with psychiatrists or psychologists in cases where there may be a psychiatric problem in addition to chemical dependency. Such a consultation will help you focus on key treatment issues and determine whether to refer your client for other services. Similarly, mental health clinicians may find it helpful to consult with chemical dependency experts regarding substance use disorders. It's a good idea to develop a network of physicians, psychiatrists, psychologists, and other professionals experienced in treating addiction that you can call on for advice or support. Keep a file of local self-help programs for clients and their families (see the Appendix for a listing of such programs). We recommend that all clinicians seek training and supervision in the assessment and treatment of both substance use and psychiatric disorders. Treatment Issues for Chemical Dependency Chemical dependency is a chronic, multifaceted disorder with many causes and adverse consequences; left untreated, it can be fatal. For these reasons chemical dependency disorders may vary considerably in origin, degree of addiction, and impairment of functioning. In a given individual, the specific effects depend on amount and frequency of use, inherited predisposition, age, health, diet, and overall lifestyle. 11 Additionally, clients who inject or smoke drugs may be affected by complications associated with the method of use, such as infection from unsterile needles or damage to lungs from smoking crack or pot.

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Each chemically dependent individual is unique. The specific treatment needs and goals of each of your clients will be different as well. Recovery from chemical dependency is a long-term process requiring abstinence as well as interpersonal and intrapersonal change. For recovery to occur, the patient must acquire information, increase self-awareness, develop the motivation to change and the skills for sober or clean living, and follow a program of change. 12 A recovery program typically involves some combination of professional treatment, participation in self-help programs, and self-management strategies. The latter, however, usually follows participation in a more formal program. Treatment of chemical dependency may incorporate a variety of therapeutic approaches:13 ·

addiction counseling

·

cognitive-behavioral psychotherapy

·

rational-emotive therapy

·

relapse prevention

·

supportive-expressive psychotherapy, a modified form of psycho-

·

dynamic therapy

Each of these approaches is based on a particular view of chemical dependency and treatment. Research indicates that a combination of addiction counseling and psychotherapy can produce positive outcomes. Recently, Kaufman outlined a three-phase approach to treating clients with dual disorders. His structure combines professional treatment with Twelve Step programs.14 Phase Oneachieving sobrietyinvolves assessments of substance abuse, psychopathology, and family functioning. In this phase, clients may need detoxification to achieve sobriety. They also may need external controls to abstain from drinking and to participate effectively in treatment. Attending self-help programs such as AA or NA can be of tremendous benefit. The counselor and the client draw up a treatment contract to identify specific areas of focus for change. Therapy emphasizes the following concrete and practical issues: ·

stabilizing physical health

·

learning not to drink or use other drugs

·

getting involved in a Twelve Step program

·

resisting social pressures to drink or to use other drugs

·

involving the family in treatment

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Phase Twoearly recoveryinvolves supportive and directive psychotherapy. Treatment addressing the concurrent psychiatric disorder begins. Patients come to accept the reality of their chemical dependency and continue working on remaining abstinent. They begin to internalize control, learning to handle anxieties and problems without turning to alcohol or other drugs. During Phase Threeadvanced recoverysupportive therapy aimed at promoting abstinence and symptom relief plays less of a role. The emphasis shifts to reconstructive therapy, which is intended to explore in-depth psychological, personality, and interpersonal issues such as intimacy, personality change, and the hidden impact of any adverse developmental experiences, such as incest and physical or emotional abuse. Areas of Emphasis in Recovery from Chemical Dependency The process of recovery addresses four major areas of functioning: physical, psychological, social, and spiritual. Which of these are given focus, and when, depends on whether your client is in early, middle, or late recovery. 15 The following information is based on our clinical experience combined with data from self-help and professional literature.16 This list highlights areas of focus during recovery from dual disorders. As a counselor, you will need to decide at what point in treatment you should address these areas with your client. Each case is different. The rate of change for each person will vary due to the nature of the concurrent psychiatric disorder. Clients also differ in their degree of interest and motivation to make changes in themselves beyond that first crucial step of abstinence. Physical Recovery 1. Eliminating alcohol and drugs from the body. Detoxification is needed if clients are unable to stop using on their own, if they develop medical or psychiatric complications associated with addiction, or if they develop a withdrawal syndrome when substances are cut down or stopped completely. Some professionals unfamiliar with the nuances of recovery tend to assume that detoxification alone is sufficient to maintain abstinence. But detoxification is nothing more than a temporary "drying-out period" if it is not followed with some combination of rehabilitation, counseling, and involvement in self-help recovery programs. Generally, if the addiction is

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severe enough to warrant detoxification, the client will need continued professional treatment and participation in a self-help program. 2. Restoring physical health. Strategies for meeting this goal include medical treatment; following a healthy diet; reduced intake of sugar, caffeine, and nicotine; adequate rest and relaxation; and exercise. Since chemical dependencies are associated with a range of medical diseases and problems, each client should receive a thorough physical examination. Any treatment or specialized counseling needed for specific conditions, such as AIDS, should be provided. Some clients also benefit from support groups or self help programs related to disorders such as compulsive overeating or such conditions as being HIV-positive. 3. Dealing with cravings to drink or use drugs. Recovering substance abusers frequently experience cravings for alcohol or drugs in the early phases of recovery. Many cues in the environment, external as well as internal, can trigger a craving. Clients need help in learning how to handle these feelings. Instruct them to get rid of drug paraphernalia (needles, pipes, papers, mirrors, etc.) and liquor. Offer cognitive and behavioral coping strategies aimed at managing and controlling such urges. (See chapter 11 for specific interventions.) Psychological and Behavioral Recovery 1. Overcoming denial of chemical dependency and accepting inability to consistently control substance use. Denial is considered the ''fatal aspect" of addiction and is a primary issue in early recovery. 17 Many of the other desired changes cannot be achieved if clients do not work through denial. The first of the Twelve Steps encourages the chemically dependent person to accept being powerless over alcohol (AA) or other drugs (NA) and to admit that use has made his or her life unmanageable. 2. Developing a desire for abstinence and establishing a need for long-term recovery and support. In the early phases of recovery, clients often feel ambivalent about abstinence or ongoing involvement in recovery. They look for the quick and easy way of dealing with their problem. At first they may have become engaged in recovery merely as a response to external pressures. However, such pressure, if sustained, can actually help clients stick with the program until they can internalize a desire for ongoing recovery. A key issue in accepting the need for long-term recovery is working through grief. Patients who give up alcohol or drugs often experience a tremendous sense of loss. Not only have they made a fundamental change

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3. Restoring emotional stability and learning to cope with uncomfortable emotional states. Many individuals with chemical dependency need help to identify and deal with a range of emotions (e.g., anger, anxiety, boredom, guilt, depression, loneliness, emptiness). In early recovery, many people experience surges of depression and anxiety that are uncomfortable and overwhelming. These emotional states may be due in part to the physiological adjustments that follow abstinence as well as to the psychological adjustments related to change in lifestyle. You should be aware that these negative emotional states are the single biggest cause of relapse among people with addictions. 18 4. Taking a personal inventory. Encourage your patients to make a list of their strengths and liabilities. The goal is to help them build on personal assets and to correct problems or liabilities. Personality characteristics perceived as problematic are sometimes called ''character defects." Twelve Step programs emphasize the need to change defects of character as part of recovery. Since many individuals with chemical dependency also have personality disorders, an inventory offers individuals a chance to evaluate parts of their personality that may need to be changed. However, the process of such change is a long-term one that requires effort on the part of the individual and help from a professional therapist or a sponsor in a self-help program, or both. 5. Assessing the impact of dual disorders on self and others. Clients can benefit from taking an in-depth look at the effects of their disorders on themselves and their relationships. Such an assessment establishes the severity of their addiction and breaks through their defense of denial. It can also help them see the direct connections between substance use and their current psychiatric, psychosocial, or medical problems. In many cases, this strategy provides patients the incentive they need to continue working at recovery and may help motivate them to involve other family members in the recovery process. 6. Changing beliefs and thoughts. The connection between distorted thoughtswhat the self-help programs call "stinking thinking"and emotional problems is well known. Cognitive interventions can help clients make psychological changes by challenging distorted thoughts about their ability to remain sober, their future, their depressed moods,

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their interpersonal problems, and so on. These strategies have been used successfully to treat a variety of mood, anxiety, and personality disorders. 19 7. Establishing a chemically free sense of identity. Some patients will feel uncomfortable at first with the idea of being "straight" or "clean." This is particularly true for those whose social networks comprise mainly other addicts. Be prepared to help your clients adjust to their new identities as recovering alcoholic or drug addicts. 8. Developing a plan for relapse prevention and long-term recovery. Outcome studies indicate that most chemically dependent people relapse at least once; many relapse frequently. Rates of relapse in psychiatric disorders are also high. Reports also suggest that both chemical and psychiatric relapses decrease in frequency and severity when the client participates in treatment devoted to preventing relapse.20 We discuss strategies for relapse prevention in greater detail in chapter 11. Social and Family Recovery 1. Overcoming denial of the impact of dual disorders on the family. Your clients must understand how the family unit and individual members are affected by their disorders. This also involves understanding how the family may have unwittingly contributed to the substance use through enabling behaviors, such as taking over the addict's responsibilities or shielding him or her from the consequences of substance use. 2. Making amends to family and significant others negatively affected by the dual disorders. This helps clients undo some of the damage that may have resulted from using alcohol or other drugs, or from problematic behaviors influenced by substance use or psychiatric illness-violence, irresponsibility, and so on. 3. Improving family relationships. By actively involving the family in recovery, you can help clients restore or improve these important relationships. Since families were often deprived of an addict's time and attention during periods of substance use, many clients need to learn ways they can increase the time they spend with family members. Spouses or children may have special treatment needs or recovery issues of their own. 4. Developing a recovery support system. A network of other recovering people, friends, and family members is invaluable for helping people in recovery. Neighbors, the church, the YMCA, AA, NA, CA, and other groups or agencies can be part of this network. Make your clients aware that others will be more willing to provide support if the clients have made amends

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and if the support relationship is reciprocal rather than one-way. 5. Participating in healthy leisure-time activities. Many recovering people need to find social or recreational activities that do not revolve around alcohol or drug use and therefore do not pose a threat to their abstinence. Since addiction often diminishes a person's ability to experience pleasure in life, some of your clients (especially cocaine and stimulant addicts) may need to learn how to decrease their need for excitement and for "living on the edge." They will have to learn to enjoy the pleasures found in normal day-to-day activities. Some alcoholics and addicts sober up only to find they have no real outside interests. Unless they develop them, they are susceptible to boredom, which increases their risk of relapse. 6. Learning to resist direct and indirect social pressures to use alcohol or other drugs. This involves refusing offers to use substances as well as coping with temptation when around others who are using. Clients can minimize these social pressures by informing trusted friends and relations about their involvement in recovery and their desire to abstain. 7. Dealing with social problems caused or exacerbated by the chemical dependency. Many clients need help with problems associated with drug use, including educational, occupational, legal, housing, and financial matters. Since homelessness is fairly common among people with dual disorders, you should be familiar with alternative housing options in your community. Be careful, however, not to address any social issues prematurely. For example, your client may need to be abstinent for a period of time before undergoing job training or going back to school. Spiritual Recovery 1. Resolving feelings of guilt and shame. Clients with dual disorders often report tremendous feelings of guilt and shame. Guilt refers to feeling bad about what one did or failed to do (i.e., behaviors, actions, or inactions). Shame refers to feeling bad about oneself or feeling "defective." 21 2. Developing meaning in life. Many clients who give up their addiction tend to think that they've lost all the joy in life. Recovery involves work to rediscover the pleasure and satisfaction available in normal day-to-day activities. Therapy can help clients explore their personal resources, set new goals for themselves, and find a new sense of purpose in their lives. 3. Restoring positive values. Addiction robs people of their sense of priorities and changes their value systems. Treatment can help restore such positive values as religious beliefs, nurturing relationships, and love.

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4. Developing a relationship with a "Higher Power" or a belief in something greater than oneself Several of the Twelve Steps of the self-help recovery programs emphasize the importance of relying on God or a Higher Power. Many dual-disordered patients find this to be the key to successful, long-lasting recovery. 5. Helping others who suffer from chemical dependency or psychiatric illness. Many individuals report that reaching out to others suffering from an addiction, psychiatric illness, or both is a primary means by which they maintain their own recovery. The Twelve Step programs provide the forum in which they can do so. Such altruism provides a mechanism for getting outside of themselves, and many feel good about giving of themselves to others. Tailoring Recovery to the Client While these recovery issues apply primarily to those with chemical dependency, we believe that they also apply in varying degrees to many clients with dual disorders. The concurrent psychiatric illness may affect the content or focus of recovery, the rate of progress, and the long-term goals of treatment. However, in many cases, the process of recovery and the issues to address are the same as outlined here. The more severely impaired a client, the more the areas of emphasispsychological, social, and spiritualmay have to be modified. Consider, for example, an individual with chemical dependency and paranoid schizophrenia, who has a twenty-year history of multiple hospitalizations following psychotic decompensation. He or she will need a different treatment approach than will a mildly depressed alcoholic with no prior history of psychiatric hospitalization and who is functioning at a fairly high level. Some individuals with dual disorders will be less able than others to change and deal with the demands of dual recovery. The chronic and persistently mentally ill are a subgroup of people with diagnoses requiring more intense attention and more resources. 22 Family Involvement We must emphasize again the need to involve the family or significant others in the treatment of chemical dependency. Doing so not only supports the recovery of the identified patient, but also helps family members who have specific recovery needs of their own. Over the last decade, much literature has identified the specific effects

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of chemical dependency on the family and the special treatment needs with which the counselor should be familiar. 23 Remember that helping family members may mean more than just referring them to a self-help program or support group. These programs excel at helping families cope with their situation, but in many instances programs need to be combined with professional counseling. Your own referral network should include the names of qualified family therapists. In general, we find the combination of self-help, family education, and family therapy to be the most effective approach to family treatment of chemical dependency. Since dual-disordered clients and their families often present more problems than those dealing with chemical dependency alone, a referral to an experienced family therapist may be highly beneficial. The recovery needs of the family depend on several factors: ·

the length and severity of the chemical dependency

·

motivation of the family member(s)

·

the presence of substance abuse or psychiatric disorders among other

·

family members

·

the nature of the relationship between the chemically dependent person

·

and individual family members

·

the nature of the concurrent psychiatric disorder

In general, family recovery involves the following: · Learning about the nature of chemical dependency, codependency, and the process of recovery for the chemically dependent person and family. ·

Learning about the psychiatric illness(es) and the process of recovery.

·

Adjusting to the new behavior of the sober family member.

· Making changes in the family system (family roles, relationships, communication and interaction styles) to reduce enabling and support the client's recovery. · Helping individual family members make changes within themselves and deal with personal recovery needs, such as working through their negative feelings about the dual-diagnosed individual. The specific nature of the psychiatric disorder will certainly have an impact on a given family's issues, concerns, and ability to engage in the recovery process. For example, coping with exposure to chronic psychotic symptoms, suicide attempts, self-destructive behavior, or repeated hospitalizations takes a tremendous toll on the family. As a counselor, you will

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need to assess the impact and look for specific ways to help relieve the family's burden. The Continuum of Care Dual-disordered clients present with a variety of symptoms and life problems. You will therefore need to be familiar with a broad range of professional and self-help services available in your area, including ·

accute care, long-term care, day hospital, and residential community programs

·

detoxification services

·

chemical dependency rehabilitation programs

·

halfway houses and therapeutic communities

·

social and vocational services

·

crisis intervention services

·

self-help programs for addiction, codependency, and psychiatric illness(es)

·

family support groups

Your ability to network with other professionals to secure services or serve as an advocate for clients and their families is crucial for a successful outcome. Plan to collaborate with case managers when necessary in dealing with more persistently mentally ill clients, since these individuals often have a variety of economic, housing, and psychosocial problems in addition to their dual disorders. Summary Assessment of chemical dependency requires a thorough history of clients' substance use and related problems. Playing a role in the assessment process are interviews with clients and their families; the use of clinical instruments such as the MAST, DAST, or ASI, which are specifically designed to identify substance abuse disorders; urine toxicologic testing for drugs; and blood or breath analyzer tests to measure blood alcohol content. Since the effects of substances can mimic virtually any psychiatric symptom, it is often necessary for the client to be drug-free for two to six weeks or more before you can accurately establish any coexisting psychiatric diagnoses. Because dual disorders are complex problems, chemical dependency clinicians may need to seek consultation with psychiatric experts, and mental health clinicians may need advice from chemical dependency experts.

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Recovery from chemical dependency means establishing and maintaining abstinence from alcohol and drugs, and making personal and lifestyle changes to support abstinence. Although some aspects of recovery apply in all cases, each client needs an individualized treatment plan that addresses specific physical, psychosocial, and spiritual concerns. The patient's particular psychiatric illness may affect which issues are addressed and when. In addition to professional treatment, a variety of therapeutic approaches can be used with chemically dependent and dual-diagnosed clients. Selfhelp groups are essential components; which programs are used depends on availability, client preference, and the specific diagnoses involved. Despite high relapse rates among patients with chemical dependency, treatment outcome studies indicate that most clients who receive treatment benefit to a significant degree. Family involvement in treatment is important for corroborating information provided by the client and for understanding the impact of the illness on the family system. Families must be recruited to provide support for the recovering individual. Also, family members may have problems and issues of their own that can be addressed both in professional treatment and in support groups such as Al-Anon (for families of alcoholics) and Nar-Anon (for families of narcotics addicts). Finally, children of dual-disordered patients may need special attention and services; too often children are excluded from assessment and treatment processes. Caregivers must be aware of the continuum of care needed to address both chemical dependency and mental health disorders. Knowledge of professional and self-help resources is essential for successful treatment of clients and their families.

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Chapter 3 Personality Disorders and Chemical Dependency An Overview Personality disorders are often associated with chemical dependency. In some cases, the personality disorder precedes chemical dependency; in other cases, the reverse is true. Nace states that "the pharmacologic effects of alcohol and drugs induce personality regression with a weakening of ego function." 1 According to this authority, alcohol and drugs reinforce a person's desire for immediate gratification, thus fostering regressive behaviors. Personality traits commonly seen among chemically dependent people with a diagnosis of personality disorder include impulsiveness, decreased ability to tolerate frustration, self-centeredness, grandiosity, passivity, and inability to endure periods of low mood.2 A personality disorder increases the individual's vulnerability to chemical dependency and complicates the course of the addiction. Studies show that people with certain personality disorders are likely to develop chemical dependency at an earlier age. They show a greater severity of chemical dependency and are more likely to have problems with polydrug abuse. Such people are at greater risk of other psychiatric symptoms, including depression, anxiety, mania, schizophrenia, and somatization. They make more suicide attempts, have a poorer prognosis, and are more prone to drop out of treatment entirely.3 According to Nace, the rate of personality disorders among chemically dependent individuals is at least 50 percent.4 Other clinical studies indicate even higher rates. Carroll reported that 79.6 percent of clients admitted to a six-month program in a therapeutic community were diagnosed with a personality disorder.5 Twelve Step programs such as NA and AA recognize that personality

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can play a significant role not just in the development of chemical dependency, but in the recovery process as well. Indeed, the Twelve Steps themselves, especially Steps Four, Six, and Ten, directly address the concept of changing "character defects." Many aspects of these self-help programs may help change an addict's character structure. Classification of Personality Disorders Personality disorders are serious conditions. Typically, individuals with these diagnoses have difficulty regulating their behavior and are less able to recognize and deal with painful emotional states. Some personality disorders feature what might be called a lack of character: individuals are unable to persevere; they show poor tolerance for frustration; they cannot delay gratification; or they become extremely upset in response to minor stress. In other types of personality disorders, individuals display what might be called bad character: they may be cruel, exploitive, manipulative, sociopathic, violent, combative, and untrustworthy. Some personality disorders are characterized by a maladaptive personality style that leads to impaired relationships, poor role performances, or subjective distress. 6 According to the a personality disorder exists when an individual's "personality traits are inflexible and maladaptive and cause either significant impairment in social or occupational functioning or subjective distress."DSM-III-R*,7 These disorders are generally apparent by adolescence or earlier. They usually continue throughout most of adult life and come to typify the person's pattern of functioning over a long period of time. Personality patterns are deeply embedded and pervasive, representing a lifelong pattern of behavior rather than a transient response to a specific difficult situation.8 People with these disorders have several features in common: a pattern of problematic relationships, a tendency to blame difficulties on others or on bad fortune, and a lack of responsibility. These individuals learn little from previous experience.9 In many cases, they make problems for themselves or perpetuate existing problems, setting into motion a self-defeating sequence of events that only makes their situation worse.10 People with personality disorders often lack specific behavioral skills, such as the ability to hold jobs or get along with other people, or they may act ineffectively or inappropriately. *Diagnostic and Statistical Manual of Mental Disorders. Third EditionRevised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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According to Beck and his colleagues, individuals with personality disorders show patterns of behavior that are either overdeveloped, underdeveloped, or a mixture of both. For example, someone with an obsessive-compulsive personality disorder is overdeveloped in terms of control, responsibility, and systematization, and underdeveloped in terms of spontaneity or playfulness. In paranoid personality disorder, a person is overdeveloped in terms of vigilance, mistrust, and suspiciousness, and underdeveloped in terms of serenity, trust, and acceptance. The individual with a schizoid personality disorder is overdeveloped in terms of autonomy and isolation, and underdeveloped in terms of intimacy and reciprocity, while one with a histrionic personality disorder is overdeveloped in terms of exhibitionism and expressiveness and underdeveloped in terms of control and reflectiveness. For all of the personality disorders, the overdeveloped patterns tend to be the counterparts of the underdeveloped patterns. 11 In addition, clients with personality disorders often experience problems resulting from inadequate control over their emotions and from distorted thinking.12 Beck and colleagues have outlined the specific profilespatterns of cognition, behavior, and affectassociated with most of the personality disorders.13 The cognitive component pertains to the individual's view of self, view of others, and core beliefs. The affective component involves the person's emotional feelings and responses. The behavioral component includes the actions that stem from a person's beliefs.14 To illustrate the concept, let us present the case of Lou, a thirty-two-year-old electrician with an obsessive-compulsive personality disorder. As revealed by his cognitive profile, Lou views himself as highly responsible; he depends on no one but himself to make sure things get done. To him, other people are simply too casual, irresponsible, self-indulgent, or incompetent. Some of Lou's core beliefs that are associated with this disorder include the thoughts, ''I need order, systems, and rules in order to survive" and "If I don't have order, everything will fall apart." Lou feels threatened by his own or others' flaws, mistakes, disorganization, and imperfections. Behaviorally, his actions stem from certain rigid rules, standards, and "shoulds." Lou holds himself, and everyone else, to extremely high perfectionist standards. As for his affect, he is constantly prone to feeling regret and disappointment. Should he fail to complete some self-assigned task or reach some impossible goal, he is vulnerable to depression. Unfortunately, not much research has been done on personality

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disorders, including their presence in people with chemical dependency. However, you should be aware of several important issues related to assessment and treatment: 15 ·

The client may show characteristics of more than one type of disorder.

· The symptoms of various personality disorders are commonly seen as traits in many normal individuals; the issue to be determined is whether those traits are harmful or maladaptive. ·

In assessing personality disorders, you may need to rely on inferred characteristics in the absence of objective criteria.

· The symptoms and patterns of a personality disorder in a given individual change over time, especially in a person who is chemically dependent. ·

Research on the relationship between chemical dependency and personality disorders can be difficult to interpret.

Types of Personality Disorders The DSM-III-R classifies personality disorders into three major groups, known as Clusters A, B, and C, based on their most prominent characteristics. Cluster A Disorders In Cluster A, which includes paranoid, schizoid, and schizotypal disorders, the individual often appears odd or eccentric and ''moves away" from other people. 16 Paranoid personality is characterized by unwarranted suspiciousness and mistrust of people, hypersensitivity, vigilance, pathological jealousy, and restricted emotions. People with this disorder may appear cold toward others, lack a sense of humor, and be unable to show tender feelings. They stay constantly on guard, looking for other people's hidden motives and believing that they are mistreated. Often such people are argumentative and tend to exaggerate their problems. If they perceive they are being abused, they may lash out in anger or launch a vicious counterattack.17 Highly critical of others, they have extreme difficulty accepting criticism themselves. Schizoid personality is marked by the incapacity to form social relationships. People with this diagnosis are emotionally cold and aloof. They lack warm, tender feelings and are indifferent to praise, criticism, or the feelings of others. Not surprisingly, such individuals have few friends; their lack of social skills makes it hard for them to date or form lasting, loving

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relationships. 18 They tend to be loners who fear closeness with others, valuing instead their independence and their solitary pursuits.19 Schizotypal personality is characterized by oddities of thought, perception, speech, and behavior. People with this disorder are often isolated; they too come across as cold and aloof toward others. They are extremely uncomfortable in social situations and seldom have any close friends or confidants. Some individuals with this personality disorder are prone to strange convictions or religious beliefs.20 Cluster B Disorders The Cluster B disorders, including histrionic, narcissistic, antisocial, and borderline personality, are those in which the individual often appears dramatic, emotional, or erratic.21 Because of the behaviors that characterize these disorders, people with Cluster B personality problems are more likely to come into contact with mental health counselors, substance abuse treatment programs, or legal authorities. In the next two chapters, we will focus extensively on the antisocial and borderline personality disorders, since these are the ones found most often among people with chemical dependency. Histrionic personality is characterized by overly dramatic, reactive, and intensely expressed behavior and by disturbances in interpersonal relationships. These people seek attention from others and love to be the center of attention in a group. Often they assume the role of "victim" or "princess" and exhibit demanding, self-centered, and inconsiderate behaviors toward others. They have a low frustration tolerance and may use crying, assaultiveness, or suicidal gestures to get their way or to manipulate and punish others whom they perceive as having offended them.22 Narcissistic personality is expressed as an exaggerated sense of self-importance or uniqueness, preoccupation with fantasies of unlimited success or power, a need for constant attention and admiration, extreme responses to threats to self-esteem, and disturbed interpersonal relationships. People with this disorder are very demanding in their relationships. Although on the surface they may appear warm or charming, others often perceive them to be shallow and lacking in genuineness.23 As a rule these individuals view themselves as special and better than ordinary people. They seek wealth, power, and prestige to reinforce this self-image.24 Cluster C Disorders Cluster C disorders, in which the individual often appears anxious or

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fearful, include avoidant, dependent, obsessive-compulsive, and passive-aggressive personality. 25 Avoidant personality is characterized by hypersensitivity to rejection, unwillingness to enter into relationships unless given strong guarantees of uncritical acceptance, social withdrawal despite desire for affection and acceptance, and low self-esteem. People with avoidant personalities shun situations in which they could be evaluated by others. They resist taking on new responsibilities because of fear of failure and don't like to attract attention to themselves, preferring to remain on the fringes.26 Dependent personality is seen in individuals who passively allow other people to assume responsibility for their lives. They subordinate their own needs to those of others on whom they depend and thus avoid having to rely on themselves. Such people generally lack self-confidence. They tend to form dependent relationships with strong caretaker types and spend enormous amounts of energy trying to please or placate them.27 Obsessive-compulsive personality is marked by a restricted ability to express warm and tender emotions, a tendency toward perfectionism, insistence that others submit to one's way of doing things (coupled with a near-total lack of awareness of how this affects the other person), excessive devotion to work and productivity to the exclusion of pleasure and value in relationships, and indecisiveness. People with this disorder are overly concerned with details, rules, systems, and schedules. They often come across to others as stiff and serious.28 Passive-aggressive personality is a pattern in which people indirectly express their feelings of anger or resentment toward others in the form of procrastination or stubbornness. Over time such behavior leads to longstanding ineffectiveness in social situations or on the job. People with this disorder covertly defy authority, although on the surface they may appear compliant and may seem to crave approval from authority figures. They tend to avoid competitive situations and prefer solitary endeavors.29 There is also a mixed personality disorder in which people display a combination of characteristics from two or more disorders. In a study of dual diagnosis in 192 patients, Daley and Salloum found that 21 percent had mixed personality disorders.30 This was the third most common personality disorder we diagnosed, following antisocial and borderline disorders. Individuals with personality disorders typically do not take the initiative to seek treatment on their own. Usually they enter treatment as a result of external pressure or to achieve some secondary gain. However, the clients who do seek treatment on a voluntary basis frequently present with

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complaints of depression, anxiety, or self-destructive impulses or actual suicide attempts. They have difficulty recognizing and dealing with a broad range of emotions. Many of them have underlying issues with anger and problems in their relationships. Research on the effectiveness of treatment interventions with personality disorders is in the beginning stages. There is still much to be learned. 31 However, cognitive-behavioral interventions appear to offer promise. The work of Beck, Freeman, and associates contains an excellent review of treatment guidelines for dealing with personality disorders.32 Summary Personality disorders are closely associated with chemical dependency. They involve specific traits and behavioral symptoms that often create distress not just for the individuals but for the other people in their lives. These disorders are classified into three clusters based on their common characteristics. Each type of disorder can be described in terms of an individual's cognitive, affective, and behavioral profiles. There is little research on effective intervention for dual-disordered clients with personality disorders, but cognitive-behavioral treatment appears to be a promising therapeutic approach.

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Chapter 4 Antisocial Personality Disorder and Chemical Dependency An Overview Among people with chemical dependency, antisocial personality disorder (ASP) appears to be the most common coexisting personality disorder. Studies suggest that between 20 percent and 41 percent of the chemically dependent meet criteria for antisocial personality disorder; conversely, 83.6 percent of individuals with ASP meet criteria for chemical dependency. 1 However, due to flaws in clinical studies, the rates of ASP among the chemically dependent may be lower than the reports indicate. People with ASP tend to have an earlier onset of alcohol and other drug problems compared to other groups of substance abusers. More men than women have ASP. There is evidence that ASP and chemical dependency share a common genetic basis. In his work, Cloninger has studied the specific behavioral problems and personality traits of alcoholics. He has found a strong hereditary pattern in what he calls the Type II alcoholic: predominantly male, with early onset of a drinking problem, and with a tendency to engage in violence and to abuse other drugs.2 In many cases, these traits also describe the individual with ASP. People with ASP display a chronic pattern of behavior in which to meet their own needs, they violate the rights of others. Antisocial behavior takes a range of forms, from direct attacks and aggressiveness to more subtle forms of conning and manipulating. This pattern typically begins before age fifteen and persists into adult life. Those with ASP have serious problems in their relationships and in their ability to function in society, yet are not likely to accept that they have such problems. Instead, they blame

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others or society for their difficulties; as a gang member sings in West Side Story, "I'm depraved on account of I'm deprived." Many people with ASP feel little or no anxiety, guilt, or remorse when engaging in antisocial acts. Such individuals usually have trouble forming or sustaining a lasting, close, warm, or responsible relationship with family or friends. 3 According to Millon, they avoid expressions of warmth and intimacy and are suspicious of others who exhibit softer emotions, such as kindness or compassion. Millon notes that the person with ASP "seems deficient in the capacity to share tender feelings, to experience genuine affection and love for another, or to empathize with their needs."4 Such people are insensitive to the needs of others and are unable to form relationships based on reciprocity, or give-and-take.5 Instead they are concerned mainly with satisfying their own needs. Because they typically have a low tolerance for frustration, people with ASP often seek immediate gratification and are frequently brash, arrogant, and resentful. Easily bored and restless, they may be unable to endure the tedium of routine or to handle the day-to-day responsibilities of a job. They may use anger and hostility to control other people and to prevent them from getting close, emotionally as well as physically. Such individuals view themselves as loners who are both autonomous and strong, who must look out for themselves, and who are entitled to break the rules of society.6 According to Beck and colleagues, these are some of the typical beliefs of the individual with ASP: I have to look out for myself. People will get me if I don't get them first. Other people are weak and deserve to be taken advantage of. What others think of me doesn't matter. I should do whatever I can get away with. If I want something, I should do whatever is necessary to get it.7 People with ASP may present themselves as sincere and mature. Since they can be charming, especially in their first social encounters, they are often able to deceive others with great skill. Sometimes they can be pathological liars. In their quest for thrills, they may take chances and show reckless behaviors. They characteristically show a lack of self-awareness and rarely exhibit the foresight one might expect, given their intellectual capacity to understand the implications of their behavior.8 Those suffering from this disorder may fail to become responsible functioning adults and thus may spend time in penal institutions. If they enter an addiction or mental health treatment system, they typically do so only under pressure from the legal system.

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Case History: Frank Frank is thirty-one years old, separated, a father of two. He came to our attention when, following an arrest for simple assault, his probation officer referred him for treatment. Having stolen since the age of ten, Frank never learned that it was wrong to take things that belonged to others. He had had several skirmishes with the law as a teenager. He has been arrested twice in the past ten years, but both times charges were dropped. Although evaluated as above average intellectually, Frank did poorly in school. He skipped class often; when he did show up, he was often disruptive and quick to start a fight, since he believed fighting was a way to show he was tougher than others. Often he came to school high on pot and beer. He quit school at seventeen, after his third suspension. Frank began drinking beer and smoking pot when he was twelve and using speed at fourteen. By age sixteen, he had begun taking barbiturates and minor tranquilizers. Frank would get buzzed up or intoxicated several times each month, usually on weekends or during school vacations. He obtained prescription diet pills from some of his female friends; if he couldn't sell the pills, he'd use them himself. Frank regularly had sex with three of the girls who supplied him with the pills. He convinced each of them that he cared deeply about her; secretly, though, he was amused that he could take advantage of them so easily. Frank's parents could not control him. His mother had her hands full with his four younger siblings. His father was an alcoholic who frequently became abusive. During his drinking bouts, he often called Frank stupid and told him he would never amount to anything. After quitting school, Frank joined the army, where he earned his equivalency diploma and completed training as a mechanic. But he was unable to adjust; frequently intoxicated, he became involved in many fights. He missed a lot of work and defied his sergeant. Within a few months, he was dishonorably discharged. A friend hired Frank to work for him as a mechanic. He did all right for several months, but he tended to come late to work. He continued getting high or intoxicated on beer and marijuana several days each week. His tolerance had increased significantly, and he experienced occasional blackouts. One day his friend reprimanded him for his tardiness. A screaming match followed, and Frank quit the job. Soon thereafter Frank got into a heated argument with his live-in mate. Frank became very angry at her for not taking his side in his fight with his

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boss. The argument grew violent. As he later told us, he "smacked her a couple timesnot hard enough to hurt her bad, but hard enough to teach her a lesson." She then left him. Over the next five years, Frank worked for three different garages. Twice he quit after arguments with his bosses, and once he was fired for not showing up following a weekend binge of drinking and drugging. Frank stated that he never worried about quitting because he knew he was a good mechanic and could always find work. During this five-year period, Frank lived with two different women. He left the first one because, as he put it, he "got bored with her." Although she was pregnant, Frank didn't want anything to do with her. He has never seen his child and expresses no interest in knowing anything about her. His second mate left him after several violent episodes during which Frank pushed her down and hit her. In addition to these live-in relationships, Frank had casual sexual affairs with many women, telling himself he was oversexed and that no one woman could satisfy his needs. His live-in mates knew about these affairs and were hurt and angered by them, but Frank says he felt no remorse for the emotional stress he caused. Frank continued moving from one job to the next. He got into many altercations with others and on at least seven occasions was involved in fistfights. He claimed that in each case others provoked him and that he had fought only to protect himself. Once, after getting fired, he beat up his boss and was convicted of simple assault. After living with a woman for six months, he married her because, as he recalled, "she put pressure on me." One year later they had a son. Shortly after the boy was born, Frank met a woman in a bar. Two weeks later he left his family and moved in with her. He has had no contact with his wife or son since. Frank says, "We didn't get along all that well anyway" and states that he has no intention of providing child support. In fact, he says, "I don't plan to see her kid either. I don't want anything to do with either of them.'' Assessment Criteria According to DSM-III-R,* criteria for antisocial personality disorder include the following: 9 *Diagostic and Statistical Manual Mental Disorders, Third Edition--Revised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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1. The patient is at least eighteen years old. 2. Onset of the disorder occurs before age fifteen, as indicated by a history of three or more of the following: ·

truancy

·

running away from home overnight at least twice

·

often initiating physical fights

·

using a weapon in more than one fight

·

forcing others into sexual activity

·

being physically cruel to animals

·

exhibiting physical cruelty to other people

·

deliberately destroying other people's property

·

deliberately engaging in fire-setting

·

persistent lying

·

stealing (with or without confronting the victim)

3. There is a pattern of irresponsible and antisocial behavior from the age of fifteen, indicated by at least four of the following: · inability to sustain consistent work behavior, such as frequent job changes, significant periods of unemployment, a serious record of absenteeism, walking off several jobs without other jobs in sight · failure to accept social norms with respect to lawful behavior, such as repeated thefts, an illegal occupation such as prostitution or selling drugs, multiple arrests, a felony conviction ·

irritability and aggressiveness, such as repeated physical fights or assault, including domestic violence (spouse or child abuse)

·

failure to honor financial obligations, such as repeated defaulting on debts, failure to provide child support, failure to support dependents

· impulsivity or failure to plan ahead, such as traveling from place to place without a job or a clear goal, or the lack of a fixed address for longer than a month ·

persistent disregard for the truth, such as repeated lying, use of aliases, or conning others for personal profit

·

recklessness, such as driving while intoxicated or recurrent speeding

· lack of ability to function as a responsible parent, such as when a child is malnourished or isn't given medical care when ill; becomes ill due to improper hygiene; depends on someone other than the parent for food or

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shelter; does not have a caretaker when the parent is away from home; or goes without necessities when a parent repeatedly spends household money on personal items ·

has not sustained a totally monogamous relationship for more than one year

·

lacks remorse for actions

4. The behavior is not due to schizophrenia or mania. Assessment Issues As a rule, clients with ASP usually seek treatment for one of two reasons: either the legal system or family members have forced them to, or they suffer from depression. Evidence suggests that even if these people have been coerced into treatment, they can still benefit. 10 The patient's motivation at intake is not necessarily a critical factor in achieving long-term success. Be alert to the fact that some people with a chemical dependency, including those with coexistent ASP, present themselves to medical or mental health institutions in an attempt to obtain tranquilizers or pain pills; the risk that they intend to abuse these medications is high. It may be, too, that they seek mental health or addiction treatment merely to avoid or postpone legal charges, or to strengthen their case prior to a hearing. Typically these clients will not volunteer information to the person conducting the assessment. Therefore, in your interview, ask your client specifically whether there are any pending legal charges or upcoming hearings. In fact, if the case has been referred to you by the legal system, you will want to review the person's legal records personally, since clients may minimize, distort, or deny legal problems or a history of antisocial behaviors. A word of caution: Although many chemically dependent individuals manifest antisocial behavior, they do not necessarily have a full-blown antisocial personality disorder. In many cases, such behavior is a direct result of their substance abuse; the behavior typically decreases significantly, or even stops, when the person becomes sober or clean and works a recovery program. The hallmark of ASP, as the criteria indicate, is a lifelong pattern of antisocial behavior. If you suspect that you are dealing with a case of ASP, consider referring the individual for psychological testing or consultation. Family involvement in assessment and treatment can be very valuable. However, it is not unusual for people with dual diagnoses of ASP and substance

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abuse to have become alienated from their families or to have lost contact with them altogether. In such cases, you should still try to explore family experiences and issues. This process may increase the individual's understanding and provide insight into current patterns of behaviors. Remember, too, that like other personality disorders, ASP can change over time. A study of two hundred opiate addicts found that half of the subjects who initially were diagnosed with ASP did not meet criteria for this disorder when assessed at the end of the two-and-a-half-year study period. Interestingly, half of the subjects who did not have an initial diagnosis of ASP acquired it during the study period. 11 These results demonstrate that many opiate addicts experience a significant change in ASP diagnosis within a three-year period. Counseling Issues Therapeutic Alliance The counselor should be aware of several critical issues in working with ASP clients. First, despite the commonly held belief that antisocial individuals do not respond to treatment, research has shown that clients with ASP do benefit from psychotherapy as part of their chemical dependency rehabilitation.12 This is particularly true if clients have symptoms of depression in addition to ASP and addiction. The ability of the ASP client to form a good working alliance with you as a counselor can be a critical factor in the success of therapy.13 Try to avoid power struggles. If the patient tries to manipulate you, do not personalize the behavior but accept it as a symptom of the disorder. Taking a more active approach to counseling also helps. In talking with your client, discuss and agree upon the goals of therapy. ASP clients frequently have more legal problems than other dual-diagnosed clients, so pay special attention to this aspect of the client's life. How you react to people with this dual diagnosis is another key issue. Strong negative reactions will impede your progress. To be effective, you must first overcome any preconceived distortions you may be holding. Such clients will challenge and test your skills, and you need to contain any hostile reaction you may experience as a result of such interactions. Guard against falling into the trap of an angry relationship. If you can learn to tolerate the less-attractive traits of an ASP client, you stand a better chance of gaining the trust needed in a helping relationship.14 However, you need to maintain distance and keep a proper perspective.

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Avoid reacting too positively, particularly if you find the client overly attractive. Discuss openly any emotional reactions to your client with your supervisor or a consultant. Your beliefs about success and progress are key themes as well. Be realistic about what impact you can have. You may have to judge success in small steps; these small steps may in fact represent significant change for the individual with ASP. One of our patients, Stan, illustrates the point. Stan was a cocaine addict with ASP who spent six months in a therapeutic community following release from prison. During treatment Stan learned to take such positive steps as calling his parents on their birthdays and sending them a card for the holidays. These were prosocial (as opposed to antisocial) behaviors that he had never shown in the past because he was incapable of thinking much about other people and what was important to them. Seen by themselves, the acts of calling and sending cards seem like small achievements. Given the context of Stan's situation, however, these acts represent movement away from self-centeredness and toward other-centeredness. Since that first step, Stan has made tremendous progress. He has been active in NA for several years, and he gives back to others by serving as a sponsor and by chairing NA meetings in correctional institutions for delinquent youth. Detoxification Settings Clients treated in detoxification settings are likely to exhibit a pattern of polydrug abuse or addiction. Such individuals can be very manipulativeand in some instances overtly hostilein their attempts to get their needs met. Many clients will freely admit to having a problem with alcohol but will minimize or deny their abuse of other drugs. This selective denial is often a treatment issue across the continuum of care. Since abstinence from all addictive substances is a goal of treatment, a thorough substance use history is necessary. Collateral sources of informationfamily members, court records, and so onare often needed to identify drug use problems. Blood or urine screens are also helpful and in some cases may be required. (See chapter 2.) Since clients sometimes take advantage of detoxification facilities, you may need to set limits on the frequency of admissions or the circumstances for admission. Making detoxification contingent on participation in a treatment program (rehabilitation, outpatient, self-help, etc.) can have therapeutic value. Try to avoid revolving-door admissions that are based on manipulation and questionable motives rather than on clinical need.

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Rehabilitation Programs People with ASP and an addiction problem can benefit greatly from residential rehabilitation programs for chemical dependency. The external controls inherent in such programs provide the structure and the firm limits essential to helping clients accept responsibility for their lives. In addition, these programs help many individuals accept the need for long-term involvement in aftercare, such as continued professional therapy and self-help programs like AA, NA, and CA. Helping clients accept the need for an aftercare plan is a significant achievement. Often, clients with ASP need help getting oriented to the realities, rules, and regulations of the residential program. You can help by holding these individuals responsible for their behavior and their participation in treatment. If they fail to take any interest in recovery or to make progress in treatment, or if they disrupt the treatment milieu, consider discharging them. However, do not discharge clients until you have asked for their feedback on their problems and have given them an opportunity to change. Clients with this dual diagnosis often test the limits of the staff by trying to find loopholes in the program's policies; therefore staff expectations must be clearly defined. You can manage manipulative and immature behaviors effectively through the use of contingency contracts. These contracts should be put in writing, with one copy given to the client and another kept by the treatment team. Terms of the contract should be concrete, spelling out explicitly what clients are expected to do and what the consequences will be if they fail to meet their obligations. People with ASP often attempt to put responsibility for their recovery on others, denying or minimizing their own role in changing. They therefore need to be held contractually accountable for progress in treatment. As the diagnostic criteria indicate, people with ASP have trouble delaying gratification and thinking before they act. Helping them to identify goals and to plan for the future is one intervention that may decrease their impulsive tendencies. A two-pronged educational strategy helps them see the potentially negative aspects of impulsive behavior as well as the positive rewards of thinking ahead. Cases in which clients are referred by the legal system require collaboration with the referral sources. At the onset of treatment, be sure your clients are informed that this collaboration will occur and have them sign consent forms. Openly discuss the specific issues that will be shared with others. For example, tell clients that you will probably be asked to provide a written summary of their participation in treatment and that you intend

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to be honest and forthright in documenting their progress. In consulting with referral sources, be as objective and factual as possible. For example, rather than stating, ''This client has a bad attitude," say, "The client failed to complete therapeutic assignments on three occasions, missed two scheduled counseling sessions," and so on. This consultation is also a good opportunity to provide the probation or parole officer with specific recommendations regarding continued treatment and involvement in self-help programs. Your clients may resist discussing their addiction or its effects on themselves and others. Be prepared to confront them with the truth about their addiction as a primary problem. If you neglect to do so, these clients are likely to participate only superficially, or they may try to sidetrack attention away from their chemical dependency onto trivial matters. Some ASP clients will ask for passes to leave the treatment facility for a variety of reasons ("I have to pay my bills," "I have to pick up a check," etc.). Avoid granting routine passes, since absence from the program is counterproductive. Whenever possible, ask clients to attend to all such matters before they begin the residential treatment program. Clients with this dual diagnosis are typically adept at finding staff members who may inadvertently reinforce the clients' pathological behavior. Therefore, it is essential that the staff collaborate closely to share information and to develop and implement appropriate treatment goals. Assigning a primary therapist for each client is one way to minimize staff splitting and manipulation. Instruct your clients to take requests, concerns, or issues to this primary therapist. In some cases, you may need to order a therapeutic discharge. Doing so sends a signal that the client cannot continue to exhibit patterns of behavior that are disruptive and that violate the rights of others. Also, this helps maintain the integrity of the treatment milieu. However, you should take this step only after the staff has offered feedback on the problem and after you have given the client the opportunity to change his or her disruptive patterns of behavior. Exceptions to this grace period would be if the client were to violate certain rules while in the rehabilitation program, such as using chemicals, becoming violent, or having sex with other residents. Each program has the right to determine how to handle these types of behaviors. Some programs will not discharge clients the first time these violations occur; other programs will. To help motivate your clients to change, review their life histories with them. Point out connections between the characteristics of their ASP

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disorder and their long-term pattern of problems in such areas as relationships, school, work, legal and criminal history, and so on. Before they can make any changes, your clients will need to identify these trouble spots and perceive the positive rewards or advantages that will result when they address these problems. At first, your clients will tend to perceive only those benefits that accrue to themselves, not necessarily to other people. For example, their motivation to stop stealing may be to stay out of jail, not because they have learned that such behaviors are wrong. The motivation to control angry or aggressive impulses may be their awareness that they could get hurt, face legal charges, lose a job or a relationship, and so on. If you can help clients see the advantages of making good choices and the disadvantages of making poor ones, they are more likely to make changes in their behavior. To achieve this goal, Beck and colleagues recommend the use of a Choice Review Exercise. In this exercise, the client is helped to make constructive decisions by using a structured format that includes three components: 15 ·

Identifying the problem and rating the client's level of satisfaction with the facts of the situation

·

Identifying choices available for resolving the problem

·

Identifying advantages and disadvantages for each choice identified People with ASP often have difficulty identifying and dealing with

emotions such as depression, boredom, and anger. A helpful intervention is to teach these clients to become aware of various emotional states and learn how to regulate and deal with their feelings. Interventions such as these often require clients to modify their beliefs as well as change their behaviors. While in a rehabilitation program, clients may begin to learn some of the basic skills for dealing with emotions. Real progress, however, requires continued work after discharge from the program. Typically, clients with ASP have poor interpersonal relationships and lack awareness of how their actions affect other people. Often, therefore, a helpful intervention is to examine and discuss ways in which their addiction interferes with current and past relationships. For example, focus attention on how the client's children may have been affected by the problem. Introducing the client to Steps Eight and Nine, the "making amends" Steps, can facilitate this process. The longer-term goals of this strategy are to improve existing relationships, develop new ones, and modify interpersonal behaviors. In some cases, clients may need to learn skills such as assertiveness or anger management.

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As a counselor, you can provide direct feedback about your clients' behaviors. You can also use feedback from other residents in the treatment milieu to point out behaviors that need to be modified and to reinforce more responsible ones. Clients with ASP are often articulate and helpful (at least superficially) in group sessions. You must therefore evaluate progress by assessing clients' behavior rather than their verbal remarks. Although our client Lois openly shared in group therapy her "sincere desire to work an honest program and become a more responsible person," she failed to show up on time for her treatment sessions or to complete assigned therapeutic tasks. Be aware that a client's sincerity cannot always be predicted accurately; therefore, the use of assigned tasks, such as readings or writing in a journal, can be helpful. For example, clients who exhibit a pattern of overly aggressive responses can be asked to record their thoughts, feelings, and behaviors associated with situations where they feel provoked. You can also work with clients to identify and challenge their distorted thoughts or beliefs about themselves, their recovery, other people, or the world in general. At first, such thoughts will probably focus on beliefs pertinent to addiction or recovery: "My addiction isn't that bad," "Recovery is a real drag," or "I can do fine without AA or NA.'' As clients continue to maintain sobriety and participate in longer-term treatment, focus can shift to cognitive distortions that relate to interpersonal relationships or their view of right and wrong. The long-term goal of this cognitive approach is to help clients move beyond thinking too much about the immediate present to looking toward the future, and to shift from focusing only on what is best for them to beginning to think about other people as well. Getting such clients to reduce their need for immediate gratification and to plan ahead will take patience, time, and effort on your part. It is not unusual for clients with this dual diagnosis to drop out of treatment early, particularly when they discover they are unable to manipulate the staff to serve their own needs. As we've mentioned, these are generally difficult clients to engage in a therapeutic relationship. Be realistic in what you expect with regard to their participation in the program and the outcome of treatment. By providing clients with structure through continuous feedback on their behavior, and by confronting problematic behavior quickly and directly, you have the greatest chance of success. Keep in mind that such clients may resist involving members of their family in the treatment. If you believe family participation is necessary in a

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given case, be firm. Otherwise the client will dictate his or her own treatment plan, which could jeopardize the outcome. Halfway Houses and Therapeutic Communities Chemically dependent clients with ASP who have serious occupational problems or criminal histories may do well in longer-term residential facilities such as a halfway house (HWH) or a therapeutic community (TC). Longer-term programs have several advantages. They provide a greater period of time for clients to take part in the self-help programs. They also give you time to counsel the client more thoroughly on educational, vocational, or interpersonal goals. HWHs or TCs that employ recovering addicts who have successfully modified personality traits offer the additional advantage of successful role models. Since many chemically dependent individuals with ASP have lifestyles that revolve around addiction and deviant behaviors, these facilities offer the chance to begin building a more positive, sober, and clean social network. Psychiatric Hospitals All of the issues outlined in earlier chapters may also apply to clients with ASP and substance abuse disorders who enter psychiatric hospitals. Typically, these individuals check into hospitals because of depression, suicidality, problems with violence, or other consequences of addiction. It isn't unusual, though, for clients to express serious depression or suicidality in the emergency room and then deny or minimize these symptoms when they meet with the treatment team. They may report depressive symptoms but show no serious signs of depressive illness. Sometimes these people admit themselves to hospitals to avoid legal problems or to buy time until their checks come. If you work in a hospital setting, you'll need to pay special attention to the addiction aspect of the dual disorder because clients may try to focus instead on the symptoms, such as depression, that brought them to the hospital in the first place. The client may need a referral to a rehabilitation program following discharge. Also, your treatment team may determine that the client does not have psychiatric symptoms requiring hospitalization. If so, then you will need to discharge the client to some other form of outpatient or chemical dependency rehabilitation. Outpatient Programs Generally, nonresidential addiction rehabilitation programs are not

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recommended for clients with ASP because of their high dropout rate. 16 These individuals are more likely to benefit from outpatient counseling if it is part of an aftercare program that follows completion of residential rehabilitation treatment. Outpatient counselors should be prepared to deal with any of the issues we've already discussed: the need for patients to take responsibility, control impulses, deal with feelings such as anger or boredom, change beliefs, improve interpersonal relationships, and so on. An approach involving group therapy provides you with an opportunity to observe clients' interpersonal behavior. In this setting, clients receive feedback from their peers rather than from authority figures. Individual therapy or family therapy can be helpful as well. Medications No psychoactive medications are known to alleviate ASP. Sometimes, however, treatment for people with this disorder may include medications that alleviate withdrawal syndromes during detoxification or that address the symptoms of major depression, if present. It is not unusual for these clients to try to manipulate caregivers in order to obtain a mind-altering substance. The search for highs appears to be an inherent part of the ASP profile. As a knowledgeable counselor, you must be skeptical of a client's requests for ''something to calm my nerves." At the same time, though, you need to assess the client carefully to determine whether there is a genuine need for a medications evaluation.17 Self-Help Programs Clients with ASP and a substance abuse problem can benefit tremendously from Twelve Step programs. As their counselor, you can help by educating them about AA, NA, CA, or other self-help programs. Familiarize them with recovery tools and literature, refer them to specific groups, and encourage them to seek a sponsor to take full advantage of the program. The self-help approach provides a context for clients with ASP to change many aspects of themselves (such as thinking patterns, behaviors, and relationships) and their lifestyles. These programs also provide an excellent opportunity to develop a recovery network of other people who are not using alcohol or other drugs and who have successfully made personal changes. Such individuals can support your clients' quest for abstinence and serve as personal examples of positive change in attitude and behavior.

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The inventory Steps are especially useful in helping clients to evaluate their personality traits and what are referred to as "character defects," and to appraise the impact of these traits on others. Just as important, these Steps provide an opportunity for clients to assess their positive traits and strengths. The making amends Steps can help clients with ASP improve interpersonal relationships. These Steps promote prosocial behaviors, empathy, and concern toward others. Making amends helps undo some of the damage caused during the addiction. The other Stepsaddressing the need for a Higher Power and the importance of carrying the message to other addictsprovide clients with the opportunity to restore or develop positive values and beliefs. By taking Step Twelve, for example, people can "give back to others." This requires outward-directed behavior, leading them away from self-centeredness and enabling them to show their concern for others. Summary The overwhelming majority of clients with antisocial personality disorder also have a chemical dependency disorder. Most of these enter treatment as a result of external pressure from the criminal justice system or a family member. Virtually by definition, antisocial behavior is closely associated with chemical dependency, but the diagnosis of ASP should be given only when clients meet strict criteria for the disorder. While treatment outcome is generally poor for ASP clients, many clients do benefit from treatment, even if they are coerced into taking part. In fact, many of these clients would not make positive changes if they were not forced to do so. A key to success, then, is the caregiver's ability to develop a nonpunitive, nonjudgmental therapeutic alliance. Treatment focusing on specific behavioral, interpersonal, and cognitive changes has a better chance of working than insight-oriented therapy. Since many of these clients have been involved in criminal acts and with the justice system, treatment must address any current legal issues. Clients with ASP and a substance abuse problem often respond well to self-help programs such as AA, NA, and CA. However, the ingrained personality traits associated with ASP require intensive, long-term therapeutic work for changes to occur; sometimes the improvements are small but significant. Many clients benefit from extended care programs such as

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halfway houses or therapeutic communities. In many cases, these clients drop out of therapy because they have trouble following rules, delaying gratification, and working toward long-term goals. With patience and dedication, however, you as a counselor can make a difference in their lives.

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Chapter 5 Borderline Personality Disorder and Chemical Dependency An Overview Prevalence of Borderline Personality Disorder Although good data are lacking, Dr. John Gunderson, one of the leading experts on this disorder, reports that the prevalence of borderline personality disorder (BPD) is estimated to be between 2 percent and 4 percent of the general population. In psychiatric clinical populations, the prevalence varies between 15 percent and 25 percent, making it the most common form of personality disorder. 1 Studies report that BPD has been diagnosed in between 13 percent and 43 percent of people with chemical dependency disorders, making it the second most common personality problem, following antisocial personality disorder, among people with dual diagnoses.2 This wide range in the prevalence rates underscores the fact that BPD is a complex disorder that can be difficult to diagnose. While ASP is much more common among men, BPD is seen twice as frequently in women. Because of the diverse assortment of problems and symptoms associated with the disorder, BPD is controversial, to say the least. More than thirty labels have been used to describe this disorder (e.g., latent schizophrenia, "as if' personality). According to Dr. John Grinder, BPD can be viewed as a spectrum disorder. On one end of the clinical spectrum is the client who manifests psychotic symptoms, who displays odd or eccentric behavior, and who may appear to lack affect or emotion. On the other end of the spectrum is the client who presents with neurotic-like symptoms such as depression.3

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Relationship Between BPD and Other Disorders BPD can interface with other non-personality (Axis I) psychiatric disorders in several ways. It can coexist with another disorder, such as major depression. It may contribute to another disorder, such as an eating disorder or a chemical dependency. Or BPD may mimic other psychiatric illnesses, such as bipolar disorder or schizophrenia. People with BPD represent a heterogeneous group with a diverse range of affective, schizotypal, and impulsive-behavioral symptoms. 4 Because of the variety of clinical presentations by individuals with BPD, Dr. Paul Soloff has proposed several subtypes of the disorder: (1) the affective borderline, (2) the schizotypal borderline, (3) the organic borderline, and (4) the core characterological borderline.5 Characteristics of BPD BPD is one of the most severe personality disorders. The person with BPD suffers from a number of psychosocial deficits. Many struggle with severe issues concerning traumatic loss or physical, sexual, and emotional abuse. As a group, BPD clients experience greater numbers of significant deaths and divorces than do clients with depression or schizophrenia. The family background is often characterized by parental addiction, depression, or other emotional disturbances. BPD is distinguished by a cluster of longstanding, ingrained traits that are prominent in the individual's character. These traits contribute to behaviors that can cause considerable difficulty in many areas of functioning, including interpersonal behavior, social adaptation, impulse control, mood, and self-image.6 Individuals with BPD are among the most difficult to treat because of the bewildering combination of symptoms and problems they present and because of their episodic decompensations.7 Interpersonal Relationships and Social Functioning On the surface, people with BPD can appear rather normal and seem to fit into social groups. Their interpersonal relationships, however, are often intense and unstable. These relationships often fail because they have insistent and unrealistic needs for others to prove their love. People with this disorder are threatened by intimacy and are extremely sensitive to actual or perceived rejection. They feel unlovable and fear being alone or abandoned. Individuals with BPD are prone to becoming dependent on others. They commonly believe that they cannot cope on their own and need

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someone on whom they can rely. 8 Yet inevitably this other person falls short in meeting their excessive dependency needs. In many cases, borderline individuals tend to see everything in terms of black and white. Other people are either totally good or totally bad; they are either heroes or villainsthere is no in-between. Thus people with BPD often have difficulty reconciling someone else's good and bad qualities. These clients can highly value and idealize another person one day, then suddenly devalue and criticize that person the next. Individuals with BPD can sometimes do well in structured, nonemotional situations. However, a job that is highly competitive or unstructured, or a critical remark from a supervisor, can trigger intense anger or feelings of rejection.9 Problems with work or school are usually not the result of inadequate ability. Instead they tend to be the consequence of emotional turmoil and impulsive behaviors.10 Frequent psychiatric hospitalizations or episodes of substance abuse, for example, can disrupt progress at school or work. Impulse Control Poor impulse control is a common characteristic of BPD. Some experts believe this trait is inheritable, since many individuals with this disorder have low levels of the neurotransmitter known as serotonin. Impulsivity may take the form of suicidal gestures or other dramatic behaviors such as running away, assaulting others, committing antisocial acts, shoplifting, abusing substances (alcohol, drugs, or food), gambling, or being sexually promiscuous. These actions may serve as defenses against feelings of loneliness and abandonment. People with BPD are subject to overpowering and transient feelings, resulting in sudden and contradictory behavior. Perceived rejection or the threat of losing an important relationship can trigger impulsive actions.11 In women with BPD, such impulsive acts usually take the form of aggression directed against themselves. In males, this aggression is more likely to be directed toward others. The tendency to be impulsive causes many clients with BPD to drop out of treatment abruptly. Often this occurs following sessions that deal with emotionally charged issues. Affect (Mood) BPD clients commonly experience abrupt and severe changes in mood. According to Dr. Theodore Millon, the depth and the variability of moods are the most striking characteristics of the client with BPD. These moods

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appear to be affected more by internal factors than external events. 12 Emotional reactions in BPD tend to be intense, out of proportion to the situation at hand, and difficult to control.13 One author referred to this trait as "emotional hemophilia." 14 Gunderson states that anger tends to be the most discriminating of the negative emotions experienced by the client with BPD, manifesting itself as bitterness, demandingness, and sarcasm.15 Trivial events can spark unpredictable outbursts of rage. Such outbursts are frequently directed at the individual's closest friends or relatives and may represent a cry for help. The intensity of anger, however, often achieves the opposite effect by pushing other people away. Many people with BPD turn their anger against themselves. Suicidal threats and gestures and self-mutilating behaviors are common. They may slash their wrists, burn themselves with cigarettes, pick fights, or have accidents. About 10 percent succeed in killing themselves. Suicidality may represent a form of self-punishment or it may be a product of depression and feelings of hopelessness, but like anger, it too may be a cry for help. Self-inflicted pain allows these individuals to escape emotional numbness.16 Following such incidents, people with BPD often report a sense of calm, stating that the experience of this pain makes them feel alive. These clients frequently report lifelong problems with low self-esteem, which contributes to chronic depression. Such depression appears to be characterologicalthat is, ingrained in the character structure. 17 Feeling empty and chronically bored are also common among clients with BPD. When separated from others, these clients are likely to feel an intense sense of aloneness or emptiness. To avoid such feelings, they may get involved in inappropriate and unhealthy interpersonal relationships. From their point of view, it is better to be in a relationship in which they are abused or mistreated than to be alone. They may abuse alcohol, drugs, or food as a symbolic way of filling this emptiness. Some people with BPD appear to lack emotions or the ability to experience and respond with emotion. Individuals with this symptom fall near the psychotic end of the spectrum of borderline disorders. Self-Identity BPD can cause people considerable difficulty in maintaining a sense of who they are.18 They lack a constant, core sense of identity. As a result, they become exceedingly dependent on others to fill in their personality blanks. Among other things, people with this disorder are vulnerable to

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joining cult groups. Identity disturbance can also take the form of low selfesteem, confusion about sexual orientation, or problems with personal or career goals. Psychosis It is not unusual for some people with BPD to experience brief psychotic episodes. They are perhaps more vulnerable to stress than others are. The pressure to reveal themselves in psychotherapy or to meet the demands of a recovery program can contribute to psychotic symptoms. These people can become psychotic using even small amounts of substances, especially marijuana, amphetamines, or psychedelics. 19 Case History: Carol Carol is twenty-four years old and single. She was referred to treatment from an emergency room following a suicide attempt. She had become extremely upset and depressed after her boyfriend ended their relationship. She drank a pint of vodka and ingested "about a half-bottle of Valiums." Her stomach had to be pumped. That was Carol's second serious suicide attempt. Three years earlier, following a big fight with a previous boyfriend, she had overdosed on pills. Carol had also cut her wrists on several occasions but never to the point that medical attention was needed. Carol, the only child of two college professors, describes her relationship with her parents as stormy, although they had always been willing to help her. Carol fights bitterly with her parents and accuses them of not caring about her. On one occasion, she showed up drunk at her father's office and picked a fight with him. For years her scholastic achievement was excellent. By the tenth grade, however, her work had begun to deteriorate. She became bored and lost interest in school. During her last year in high school, she began drinking heavily and frequently got drunk on weekends. Carol also smoked pot several times each week and snorted cocaine about twice a month. While intoxicated, she wrecked the family car; her parents didn't report the accident to the police or the insurance company, choosing instead to pay for the damage out of pocket. Carol was picked up once for public drunkenness and another time for disorderly conduct, but both times her parents paid her fines and charges were dropped. When she was fourteen, Carol was arrested for shoplifting, but her parents repaid the store and charges were not pressed. She has admitted to at least a dozen episodes of shoplifting since, but has never gotten caught.

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Carol has stolen from her parents as well, in order to get money ''to party," she says. Since graduation, she has held a series of minimum-wage jobs for an average of ten months each. She quit three jobs as a sales clerk because she became bored. Once she was fired from a road construction job for being drunk while working. At fourteen, she started a long pattern of sexual promiscuity. She says she "partied a lot and had sex with older boys." When she got older, Carol began bar-hopping. Carol has admitted that she was very lonely and tried to avoid this terrible feeling by picking up men in bars. An attractive woman, she was able to meet men quite easily, particularly after having a few drinks to make her feel more sociable. After leaving her parents' home, she had a difficult time coping with being alone. Despite her active sexual involvement with multiple partners, she never used birth control; she wondered if she was "100 percent female," since she never became pregnant. Carol has had two sexual relationships with women. Carol established three relationships with men that she describes as close. Each of these relationships, however, was characterized by bizarre or chaotic behavior. For example, she shaved her head at the request of one of her male lovers. The next day, though, she felt embarrassed and bought a wig. All of her relationships ended because of her incessant demands, and each time she became very depressed, thought about suicide, and significantly increased her alcohol and drug intake. She once burned herself with a cigarette when she was upset with another male friend and stated, "I did not feel it." In another instance, she walked into traffic while high on vodka and pot. Carol never remained alone for long. On two occasions, she moved in with a man after knowing him for just a few days. She frequently made poor decisions on impulse without thinking about long-term consequences. Assessment Criteria Literature is available describing borderline personality disorder 20 and the families of borderline individuals,21 but there are limited data on the BPD client with comorbid chemical dependency. According to DSM-III-R,* at least five of the following eight criteria must be met for BPD to be diagnosed. These criteria must characterize the *Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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client's current and long-term behavior and must cause either significant impairment in social or occupational functioning or subjective distress. 22 1. There is a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of overidealization and devaluation. This pattern may be characterized by marked shifts of attitude, by idealization or devaluation, or by manipulation, in which the person consistently uses others for his or her own ends. 2. Impulsiveness appears in at least two areas that are potentially self-damaging. These behaviors may relate to spending, sex, gambling, alcohol or drug use, shoplifting, reckless driving, or binge eating. 3. There are instances of affective instability, that is, marked shifts from normal mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days. 4. The patient exhibits inappropriate, intense anger or lack of control over anger. The person may frequently display anger, appear constantly angry, or get into recurrent physical fights. 5. There are recurrent suicidal threats, gestures, or behavior, or self-mutilating behavior. 6. There is marked and persistent identity disturbance manifested by uncertainty about at least two of the following: self-image, sexual orientation, long-term goals, career choice, or types of friends desired and preferred. 7. The patient experiences chronic feelings of emptiness or boredom. 8. The patient makes frantic efforts to avoid real or imagined abandonment. Assessment Issues Individuals with BPD often present with a range of problems or symptoms that can change from week to week. These include depression, suicidal behaviors, substance abuse, and a vast array of interpersonal problems or relationship crises. Some individuals will also present with psychotic symptoms. Again, consultation with a psychiatrist or psychologist can be highly useful. Psychiatric care is often needed for clients who have decompensated and become psychotic, who are suicidal and self-destructive, or who exhibit serious mood disturbances. Once stabilized from acute psychiatric symptoms, these patients can then be evaluated to see if they are candidates for a chemical dependency treatment program.

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This group of clients is very susceptible to prescription drug abuse as well as alcoholism and other chemical dependencies. Therefore, ask specifically about use and possible abuse of a wide variety of substances. Counseling Issues Clients with BPD are often dramatic, presenting themselves as being in a constant state of crisis. The number of problems they face may seem endless. They demand or beg for immediate attention. Sometimes they use flattery to control or manipulate others, including their caregivers, in order to get their needs met. Their profound dependency needs result in disruptive behavior across the continuum of care. Developing a therapeutic alliance with these clients requires you to be patient, supportive, and empathetic. Avoid becoming overwhelmed with the multiplicity of their problems and demands. This complex mix of symptoms and crises makes it impossible to define one approach to treating these individuals. No psychosocial counseling or psychotherapy approach has been found to be superior to another. Long-term dynamic psychotherapy has been the traditional treatment for this disorder, although in recent years a variety of other treatments have been used, including cognitive-behavioral therapy, relationship management therapy, group therapy, and multimodal treatment. 23 Improvement for some of these clients may mean a change from ''moderately severe impairment to modest impairment."24 You may detect such gains if the patient shows slight reductions in the number or degree of reported problems, fewer hospitalizations, or increased time between hospitalizations. Generally, counseling interventions are intended to help clients improve compliance with treatment, increase their control over emotions and impulses, improve interpersonal relationships and interpersonal style, improve other areas of psychosocial functioning, decrease negative thinking, and enhance their sense of identity. As in dealing with antisocial individuals, be realistic about what can be accomplished in counseling. Avoid setting expectations that are too high. Detoxification Settings Clients found in detoxification settings are likely to be very needy and attention-seeking. They will act out if they perceive their needs are not being met. They may, for example, sign themselves out against medical advice even if physically sick from complications related to alcohol or

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other drug addiction. They may exaggerate their withdrawal symptoms in an effort to manipulate medical staff into giving them higher doses of medications. During detox, such clients commonly demand immediate attention for a number of psychosocial problems. You can help these individuals tolerate conflicts and frustrations simply by providing support and reassurance. Work with clients to prioritize their problems and to focus on one problem at a time. The primary issue in this setting will be the addiction, unless severe psychiatric symptoms emerge during the course of detoxification. Since inpatient chemical dependency treatment can benefit these clients, motivating them to enter a structured rehabilitation program following detoxification is an appropriate treatment goal. Clients who continue to exhibit serious problems with mood, psychotic symptoms, or suicidality after being detoxified should be referred for psychiatric care, preferably in a dual diagnosis program. If you decide a BPD client does not need a rehabilitation program, refer him or her to other types of ongoing treatment, such as hospital programs, intensive outpatient programs, or outpatient therapy. Ideally, ongoing therapy will take place in a treatment program or with a clinician who understands both BPD and chemical dependency. Chemical Dependency Rehabilitation Programs The patterns of neediness and manipulation associated with BPD will also be evident to staff members in residential rehabilitation programs. In fact, these patterns may be more apparent, since clients spend considerably more time in a residential program than in detoxification. Be ready to set limits on these individuals from the onset of treatment, particularly since they will use their numerous physical or psychosocial problems to deflect attention away from the addiction. Limit-setting applies to a variety of contexts, from individual and group counseling sessions to general behavior on the unit. For example, you can tell a client that the major emphasis of individual sessions will be on the problem of chemical dependency and its impact on his or her life, but that there will be time at the end of each session to discuss one other concern or problem. Resist any attempt by the client to exceed the time limit of each session. Because BPD clients often try to "split" or polarize the staff, it is essential that the treatment team work in close collaboration. In some instances, splitting occurs when the client pits one discipline against the other. For example, clients may instigate opposition between the doctor and the

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counselor, nurse, or social worker by providing each caregiver with conflicting information. In other instances, clients may go from one staff member to the next, attempting to get their needs met. Such individuals are adept at figuring out which staff members can be manipulatedand how. The neediness may appear in the form of constant requests to staff members for help with a variety of insolvable problems that only deflect focus from the chemical dependency. To manage this behavior effectively, staff members should redirect clients to their primary counselor. The counselor must then set firm limits regarding the length, time, and place of sessions. If you don't set such limits, you will find yourself in endless counseling sessions in the hallways, the dining room, or other places where you casually encounter clients. Limit-setting is therapeutic because it helps BPD clients develop their tolerance for frustration. In some instances, staff members other than the primary counselor can be brought in to address special problems. We treated a client who presented a long litany of physical complaints; focusing on these ailments distracted him from dealing with his addiction. At every opportunity, he cornered any passing staff member, from secretary to counselor to doctor, and vented his problems. We decided to set limits by giving him a brief weekly session with a physician, during which he could discuss these complaints. As a result, we heard fewer remarks about his physical condition and were less likely to be the targets of his manipulation. Be aware of the tendency of people with BPD to perceive others in terms of being all good or all bad. You may be seen as sensitive and understanding one day and cold and uncaring the next. This is particularly true if clients perceive that their needs are being frustrated. The process of rapidly switching from idealizing their counselors to despising them is a hallmark of people with this disorder. Be wary if you find the patient placing you on a pedestal; provide yourself with ongoing reality testing about your role in treatment. Counselors who understand this dynamic of borderline personality disorder know not to take such reactions personally. Inexperienced counselors often overreact to this dynamic: they may feel extremely good about themselves when praised by clients but feel upset or inadequate if clients are critical or hostile. If you establish a therapeutic relationship, you may then discuss the client's strong negative reactions. Keep in mind, though, that a working alliance with these individuals is generally very difficult to maintain over the long term. You'll need to muster all your patience. A primary goal of treatment is to help clients tolerate these powerful

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emotions and conflicts without resorting to mind-altering chemicals. 25 Be ready to help clients understand their anger and evaluate its appropriateness. Teach clients specific anger management techniques to reduce the impact of their anger on others. People with BPD have poor impulse control. This means they are at high risk of terminating treatment prematurely. Often they drop out because of an underlying fear of being abandoned by the counselor. In essence they are saying, "I'll reject you before you reject me." Encourage your clients to discuss thoughts or feelings about leaving treatment as soon as they arise. Also, be aware of a tendency for a "flight into health," in which clients prematurely claim they have achieved their treatment goals, are back in control of their lives, and are ready to leave treatment. On the other hand, these clients struggle with separation issues and may have difficulty terminating with a counselor or staff members with whom they have had a positive treatment experience. As discharge nears, they sometimes suddenly present with one crisis or another. It's important that you understand the trap posed by this dynamic. Instead of responding to the "crisis," help clients discuss their thoughts and feelings about leaving the program and terminating the therapeutic relationship. During rehabilitation treatment, clients will usually present other problems that they feel need immediate attention. Maintain focus on the chemical dependency issue. Facilitate recovery by setting limits on phone calls and visitors, since these clients often experience intense responses to contact with other people and events. These contacts can snowball into perceived crises. As a result of the stresses associated with involvement in a treatment community, some clients may decompensate and become psychotic during rehabilitation. The immediate goal in such cases is to stabilize the client's psychiatric condition. This often requires transfer to a psychiatric ward and the use of antipsychotic medications. People with borderline personality disorder can have a profoundly disruptive effect on the therapeutic milieu as well. The behavioral patterns they demonstrate in interactions with staff members also show up in interactions with other patients. Their profound neediness means they may monopolize group discussions. Maintain the integrity of your group by drawing others into the discussion. Resist the temptation to conduct individual counseling with BPD clients within the group session. Make sure, too, that these clients do not deflect discussions of recovery issues by introducing irrelevant material, such as complaints about the food served in the

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cafeteria. Be alert for signs of splitting, where group members diverge into opposing camps. Focus on the process of the group interactions rather than the content of the discussions. Use the group process to elicit feedback about the client's behaviors; reinforce positive behaviors and point out those behaviors that are perceived by others as causing problems. Rephrase negative feedback in a positive light so that clients do not experience rejection (e.g., "Bill, the group is saying that they feel more is accomplished when you don't get up and leave in the middle of discussions, especially since you share important ideas and experiences"). Halfway Houses and Therapeutic Communities Be cautious about making referrals to halfway houses and therapeutic residential communities, since BPD clients sometimes regress in these institutional settings. Programs that are highly confrontational are especially difficult for people with BPD to tolerate. If you do send them to a halfway house, it's a good idea for the client to contract for a specific period of time. Any of the issues discussed previously can continue to be addressed in these treatment settings. Psychiatric Hospital Individuals with a dual diagnosis of BPD and chemical dependency frequently are hospitalized in psychiatric facilities as a result of serious mood disturbance, suicidality and other self-destructive behavior, or psychotic decompensation. These clients may enter the hospital voluntarily or as a result of involuntary commitment. The primary goal of psychiatric hospitalization is to stabilize the acute symptoms. Often a combination of medication and psychosocial therapies is used in inpatient hospitals. Alcoholism and drug abuse often are factors in psychiatric hospitalization and must be addressed. Educate patients about the impact of drug and alcohol use on their psychiatric symptoms. Patients can also benefit from basic education and counseling on alcohol and drug abuse, relapse prevention, depression, and Twelve Step programs. While hospitalized, patients should attend AA or NA meetings. Be aware that patients sometimes have negative reactions to meetings held in the psychiatric hospital as opposed to meetings that take place in the community setting, where, as a rule, members are often doing much better. In fact, many have more significant periods of recovery than those who are currently hospitalized. Inform your clients that there are many types of AA and NA meetings and that community meetings are often different in tone from those held in

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the hospital. If you think it would be helpful, arrange for clients to attend some community meetings while they are in the hospital. Depending on the individual client's needs, other issues discussed earlier (interpersonal problems, dealing with feelings, controlling impulses, etc.) may also be addressed in the psychiatric setting. For clients who have previously been hospitalized, it is helpful to review the circumstances leading to the hospitalization. The goal is to help clients learn to identify warning signs of relapse so that they may take action to reduce the chances of hospitalization in the future. However, clients must understand that hospitalization cannot always be prevented and in some instances is necessary in order to stabilize them psychiatrically. Some individuals with BPD need ongoing treatment in a long-term hospital. These usually are the sicker individuals who have more complicated and longstanding difficulties. The counselor can help these patients by preparing them for the transfer to another type of psychiatric hospital. Outpatient Treatment Since the client who has both chemical dependency and BPD exhibits problems in many areas of functioning, long-term outpatient treatment is often needed in order to support the gains made in residential programs. Limit-setting and structure are important here too, especially in the intervals between counseling sessions. Set limits on families as well; otherwise you may be swamped with calls from relatives reporting problems with your client. Use contracts to spell out acceptable and unacceptable behaviors. Avoid involving clients in multiple treatment agencies to reduce problems caused by splitting. Self-Help Programs AA, NA, and other Twelve Step programs benefit many of these individuals in several ways. They help them meet their need to be with other people, and they provide a structured program (i.e., recovery meetings, Twelve Step program, etc.) to help them deal with some of their problems. Sponsors who set limits and provide a positive, supportive role model are invaluable assets. Avoid using more than one sponsor. Medication Issues Not all clients with BPD will need medications. However, research has demonstrated that medications help many of them. 26 Clients present with

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a wide range of affective, cognitive, and impulsive behavioral symptoms. The medications used, therefore, will depend on the specific symptom cluster presented by the individual client. Neuroleptics, antidepressants, and anticonvulsant medications are the most commonly prescribed drugs for individuals with BPD. Neuroleptic drugs such as haloperidol (Haldol) are widely used with patients who exhibit psychotic symptoms such as referential thinking, paranoid ideation, derealization, depersonalization, and distortions of thinking. This medication can also have a positive impact on the client's depression, anger, and hostility. 27 Antidepressants are used for patients who exhibit primary affective symptoms such as depression. These medications include monoamine oxidase inhibitors such as tranylcypromine (Parnate) and tricyclic antidepressants such as amitriptyline (Elavil). Anticonvulsants such as carbamazepine (Tegretol) have been used to treat depression, impulsivity, and psychotic symptoms associated with the disorder. Tranquilizers are not usually recommended, for two reasons: people with BPD tend to abuse such medications, and tranquilizers may disinhibit their potential for impulsive aggression.28 Medications are generally used to treat acute symptoms in the short term and are not usually recommended for long-term maintenance therapy. Pharmacotherapy is at best an adjunct to psychotherapy. Some patients are unable to benefit much from psychotherapy until their symptoms are first stabilized on medication. Medications may have problematic side effects and can worsen certain aspects of the disorder, such as suicidal thoughts or behavior. Other common dangers include the potential for abuse, overdose, noncompliance, and interactions of medications with alcohol or street drugs.29 Closely monitor clients who are taking medications and evaluate them for impulsive and self-destructive behaviors. Treatment with mood stabilizers, antimanic drugs, or certain antidepressants also requires frequent blood tests to evaluate for adverse effects on the client's blood count. Summary Borderline personality disorder is one of the most complex, controversial, and debilitating of the personality disorders. Many people with this diagnosis also have significant alcohol and drug problems in addition to a wide array of mood and interpersonal problems. BPD is the second most

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common personality disorder found among those with a chemical dependency diagnosis. Because of their personality characteristics and the many life problems caused by these illnesses, clients usually need long-term treatment. Unfortunately, impulsivity is a common symptom of BPD that often causes people to terminate treatment early. A variety of psychosocial treatments and self-help programs benefit clients with BPD and chemical dependency; some may also require medications for control of psychotic, affective, and behavioral symptoms. Despite the complexity and severity of these combined disorders, many clients make significant progress while in treatment.

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Chapter 6 Depression and Chemical Dependency An Overview Prevalence of Depressive Disorders According to the ECA community survey, more than 27 percent of individuals with depressive disorders also meet criteria for chemical dependency. 1 Clinical studies indicate that the prevalence of current depressive illness among people with substance abuse disorders ranges from 14 percent to 34 percent, and the prevalence of lifetime depressive illness among this population ranges from 35 percent to 69 percent.2 A study by Hesselbrock of 331 alcoholics in five treatment programs found that 52 percent of female alcoholics and 32 percent of male alcoholics met criteria for major depression.3 Bedi and Halikas's study of 421 alcoholics found that 43 percent of females and 29 percent of males experienced major depression.4 Several other studies show that rates of chemical dependency are high among individuals with depression or bipolar disorders. Relationships Between Depression and Chemical Dependency The association between substance abuse and depression has long been known.6 People with one of these diagnoses are at higher risk of acquiring the other. Affective symptoms can be the cause or the effect of chronic use of alcohol or other drugs. Many alcoholics and drug addicts experience symptoms of depression in the early stages of abstinence. Cocaine addicts frequently have severe depression when ''crashing" after a cocaine binge. This type of depression, known as organic affective disorder, is primarily due to the pharmacologic effects of substances on the central nervous system. In many cases, affective symptoms remit once a person abstains from

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substance use for several weeks or longer. However, many alcoholics and drug addicts experience continued depression even after they have been free from substances for a month or more. Such depressions may result from the psychosocial problems caused or worsened by addiction, including excessive guilt, loss of significant relationships, and loss of economic or occupational stability. Use of alcohol or other drugs may trigger symptoms of affective illness. For instance, a biologically vulnerable individual may experience a first manic episode following the use of stimulant drugs. Hallucinogenic drugs such as LSD or PCP ("angel dust") have been associated with manicdepressive psychoses in several studies. 7 Many individuals with mania also experience episodes of depression. However, the use of substances can also partially or totally mask symptoms of affective illness. As a result, symptoms of depression or bipolar disorder may emerge after a period of detoxification or total abstinence. Some clients tend to use alcohol or other drugs to medicate the symptoms of their illness. Alcohol use is more often associated with mania than with the depressed phase of bipolar disorder; however, use of chemicals can also increase as a response to depressive symptoms. The course of recovery from depressive illness can be affected by chemical dependency in that some chemically dependent individuals are more likely to relapse to alcohol or other drug use when depressed. Depressive and chemical dependency disorders may also develop independently and not be interrelated at all. For instance, an individual recovering from alcoholism can experience an episode of major depression months or years after becoming sober.8 Conversely, a person in remission from depression may get hooked on drugs or alcohol. Characteristics and Effects of Depressive Disorders According to the APA, the essential feature of an affective disorder is a "disturbance of mood, accompanied by a full or partial manic or depressive syndrome, that is not due to any other physical or mental disorder."9 Confusion sometimes arises concerning the terms mood and affect. Mood refers to a prolonged emotion, such as depression or elation, that influences the individual's entire psychic life (thoughts, feelings, judgment, and so on). Affect refers to the outward manifestation of feeling or emotion. Laughing, for example, is an affective display of the emotion of happiness, while crying can be an affective display of either sadness or happiness. Affective disorders influence the individual's behaviors and relation-

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ships. Any area of functioningphysical, emotional, social, interpersonal, familial, sexual, occupational, spiritualcan be altered to various degrees, depending on the duration and severity of the mood disorder or the chemical dependency, and depending on the coexistence of other physical or psychiatric illnesses. Because substance use impairs judgment, reduces impulse control, and worsens symptoms, people with affective disorders are at greater risk for suicide. According to a report to Congress on alcohol and health, 20 percent to 36 percent of suicide victims had a history of alcohol abuse or were drinking shortly before their suicides. 10 A discussion of suicidality and intervention appears at the end of this chapter. Depressive disorders create stress on other family members and on the family system as a whole. 11 Relatives experience a kind of fallout from the disorders. They may assume they are responsible for causing the depression or feel they constantly have to ''walk on eggshells" when dealing with their afflicted loved ones. In cases involving suicide threats, attempts, or completion, the burden on families is even greater. Major Depression The main feature of major depression is a depressed mood or loss of interest in most or all of one's usual activities. This state is persistent and is accompanied by other symptoms such as appetite disturbance, change in weight, sleep disturbance, agitation (inability to sit still or a tendency to pace), slowed or decreased speech, slowed body movements, decreased energy, feelings of worthlessness or guilt, difficulty concentrating, or suicidal thoughts or attempts. Such symptoms often cause people to withdraw from family and friends or to neglect activities that formerly provided pleasure. Depression often precedes chemical dependency. Some clients drink alcohol to relieve their symptoms. Alcohol, however, is a central nervous system depressant, and drinking will frequently make the symptoms worse. In other cases people may become more depressed because of problems associated with their chemical dependency: a decrease in self-esteem, excessive guilt over drinking or drug-taking behaviors, or losses associated with addiction. When these chemically dependent individuals sober up, evaluate their lives, and realize the problems arising from their substance abuse, they may become depressed.

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Another group of people experience depression as a result of chemical imbalances in the brain. This type of depression, which may be inherited, is biological in origin and is referred to as meaning "arising from within."endogenous, Medical illnesses, such as thyroid disorders, or other psychiatric disorders, such as schizophrenia or personality disorders, can contribute to existing depression. In some cases, though, the symptoms of medical illness may fit the pattern of depression when, in fact, they arise from other treatable causes. Case History: Beth Beth is forty-four years old, married, and the mother of two teenage girls and a ten-year-old son. She is a free-lance writer who also teaches parttime at a local community college. Her husband owns a successful home-remodeling business. Raised in a middle-class home, Beth describes her parents as loving and supportive. Her father, a sales executive, and her mother, a teacher, are both retired and are very involved in the lives of Beth and her family. Her mother had periodic bouts with depression during Beth's childhood; she was hospitalized twice for brief periods. Beth's mother also has a history of dependence on tranquilizers and alcohol, although she has not used any such substance in more than ten years. Beth suffered periodic bouts of depression during her adolescence and young adulthood. During these depressive episodes, she tended to drink heavily, often to the point of intoxication. Beth became more and more unable to control her alcohol intake. On occasion she got drunk even when she was not depressed. She experienced numerous blackouts and often argued with her husband over her drinking. He insisted that she needed to stop or cut down. Beth thought that since she often went weeks at a time without drinking that she didn't have a problem with alcohol. Her episodes of depression decreased in her thirties but increased in her forties. She rationalized these bouts as resulting from her "mid-life crisis." Sometimes her depression seemed to be triggered by events and problems that occurred in her life, but other times, she became depressed for no apparent reason. During these episodes, which usually lasted a month or so, Beth lost interest in her writing and derived little pleasure from her hobbies. Since she couldn't write, she felt guilty and useless. She also lost interest in teaching and became indifferent to her students, finding it

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immensely difficult to correct papers or assign grades. Beth sometimes canceled classes because she felt "too down in the dumps" or thought she "just didn't have the energy." Some days Beth felt so bad she could barely drag herself out of bed. Since she also lost her sexual interest during depressive bouts, Beth felt guilty for letting her husband down. Although alcohol made her more depressed, she would still drink to excess. Following drinking binges and family arguments, Beth reproached herself, telling herself that she was a burden to her family and they might be better off without her. Recently, she entertained thoughts of taking her life by purposely wrecking her car. She admitted she "didn't have the nerve to do this sober and would have to be drunk first." Assessment Criteria The DSM-III-R* criteria for major depressive illness include the following: 12 1. At least five of the following symptoms have been present nearly every day during the same two-week period and represent a change from previous functioning. At least one of the symptoms is either a depressed mood or a loss of interest or pleasure. ·

depressed mood most of the day, nearly every day, as indicated either by subjective account or observation by others

·

markedly diminished interest or pleasure in all, or almost all, activities most of the day

·

significant weight loss or gain when not dieting (e.g., more than 5 percent of body weight in a month), or decrease or increase in appetite

·

insomnia or hypersomnia (excessive sleep)

·

psychomotor agitation or slowing down

·

fatigue or loss of energy

·

feelings of worthlessness or of excessive or inappropriate guilt

·

diminished ability to think or concentrate, or indecisiveness

·

recurrent thoughts of death, suicidal thinking without a specific plan, a suicide attempt, or a specific plan for committing suicide

2. It cannot be established that an organic (biological) factor caused or *Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised [ DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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sustains the depression, nor is the depression a response to the death of a loved one or some other emotionally disturbing circumstance. 3. At no time during the mood disturbance have there been delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms. Assessment Issues In counseling people who suffer from depression, you must gather a thorough history to verify the patterns of alcohol and other drug use and depressive symptoms. A detailed family history from the client as well as the other family members may determine if depressive illness is present, since chemical dependency and depressive illness tend to run in families. 13 In some families, both chemically dependent and depressed family members may be found concurrently. Remember to ask your clients if they experienced the symptoms of depressive illness before any alcohol- or drug-related problems arose, and if they experienced symptoms during abstinence. It's important, too, that you ask specifically about past and present suicidal thoughts, attempts, or plans. You will need to stabilize suicidal clients before chemical dependency treatment can proceed. Depression scales are available that allow you to determine the presence and degree of the disorder. The Beck Depression Inventory (BDI), for instance, consists of twenty-one questions that produce a numeric score assessing the level of depression, from "normal" ups and downs to "extreme" depression.14 The BDI can also be used to monitor a person's moods over time and to spot increases in depressive symptoms, as well as improvements. This can be especially helpful, since depressed individuals tend to minimize or overlook improvements in their mood. In cases where it is difficult to differentiate an actual depressive disorder from the effects of chemical dependency, collaboration with a psychiatrist or psychologist is highly recommended. This is particularly important if symptoms persist after abstinence from alcohol and other drugs for a prolonged period of time (six weeks or longer). Since medical diseases such as hypothyroidism and viral infections can masquerade as depression, your client should be given a complete physical examination to rule out these potential problems. Counseling Issues Among the psychotherapeutic strategies used to treat depression are

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interpersonal, cognitive-behavior, supportive, and dynamic therapies. 15 These techniques may be used whether or not the client is taking medication. Considerable evidence shows that these treatments are effective with depressive disorders. However, little data exist about their efficacy in treating depressed individuals who also have chemical dependency. Clinicians generally agreeand literature supports the notionthat the presence of chemical dependency can complicate recovery from depression. On the other hand, clients with both depression and chemical dependency often respond more positively to treatment than those with other psychiatric disorders such as schizophrenia or personality disorders. Since the symptoms of depression are made worse by drinking or drug abuse, depressed clients often enter the treatment system via detoxification. (A suicidal gesture or signs of severe depression may indicate the need for detoxification on a psychiatric ward.) Once mood has improved so that the client can concentrate on the demands of treatment, and if suicidal thoughts have subsided, the client can be referred for chemical dependency treatment or a dual disorders treatment program. As a counselor, part of your task is to instill hope. Reassure clients that they are likely to feel better if they stay off drugs or alcohol. Emphasize that treatment can help decrease depression and help solve their problems, particularly if they learn new ways of dealing with their thoughts, feelings, and relationships. A supportive and psychoeducational approach to counseling is most useful at first; for example, assigning homework between sessions can facilitate change. Remember, however, that depression robs people of energy and motivation. Be realistic in your expectations. Make sure assignments are reasonable and that they help clients focus on a specific problem or concern. For people with depression, the experience of success, even in small steps, can improve self-esteem and mood. Generally, counseling interventions address four problem areas associated with these dual disorders: (1) handling feelings, (2) changing thoughts and beliefs, (3) changing behaviors, relationships, and lifestyle, or developing or improving social skills, and (4) participating in self-help programs. When clients are taking antidepressant medications, you may also need to work with them in examining their perceptions and beliefs about taking medication. Some clients, for example, may be under pressure from other recovering individuals to stop taking their prescription medication. Dealing with Feelings or Emotions A variety of counseling interventions help depressed clients deal with

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their feelings or emotions. These interventions, which should be individually tailored to each client, include any or all of the following: monitoring feelings, identifying and expressing feelings, exploring specific feelings commonly associated with depression (such as guilt, shame, powerlessness, anger, and grief), and connecting feelings with thoughts and behaviors. Let's look at each of these more closely. 1. Ask clients to monitor feelings or emotions. Doing so helps them to assess the severity of mood symptoms and to track changes in mood over time. This strategy also reveals how a person's environmental context and thoughts can contribute to various feelings. You may want to instruct clients to keep a journal in which they record their feelings, the circumstances in which the feelings arose, and the ways they dealt with those feelings. Consider asking clients to fill out specific mood monitoring forms. 2. Encourage clients to identify and express feelings. Some clients may need coaching before they can recognize, label, and express such emotions as sadness, guilt, powerlessness, anger, emptiness, or joylessness. Teach clients how emotions manifest themselves in different forms: physical signs, thoughts or internal messages to the self, or actions. Once they can identify these feeling states, they can explore both the causes and the effects. Doing such work in therapy prepares them to recognize and express feelings appropriately in social situations. Expressing feelings can do a lot to relieve depression. It can also facilitate the process of developing a trusting therapeutic relationship. Acknowledge your clients' feelings and, without being condescending, further encourage your clients to express them. You may need to caution them, however, about expressing dysphoric feelings too often in front of family and others. Some experts suggest assigning clients specific times of the day as their periods to "feel bad." 16 Be aware, too, that dysphoric feelings may not totally remit in all individuals, and that you may need to help them to tolerate some degree of depression. 3. Help the client deal with guilt and shame. The chemically dependent person typically experiences guilt and shame.17 Guilt stems from such behavior as making hurtful statements to a spouse or failing to take an interest in a son or daughter. Shame is the feeling that one is defective or a failure. In our experience, people with a dual diagnosis of depression and substance abuse typically feel more intense shame and guilt. They judge themselves in harsh and negative terms: "I'm worthless"; "I'm no good"; "If I have these disorders, there must be something terribly wrong with me."

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Discussing these feelings and thoughts in treatment is one way to begin understanding and dealing with them. Many of the Twelve Steps, especially Steps One, Four, and Five, are quite useful in addressing guilt and shame. Since these clients are liable to condemn themselves, be ready to help them challenge and change negative self-statements. Instead of saying, "I'm worthless," clients can learn to change this statement to something like "I feel bad about what I have done. But I'm trying to make things better. I'm not perfect, but I'm not a bad person. In fact, I have some good qualities." Or if a client says, "I'm doomed to have these disorders and will never get better," he or she can learn to say, ''People with these disorders do get better. Just because I'm feeling bad now doesn't mean I'll always feel this way.'' 4. Help clients confront feelings o f powerlessness. Expressing frustrationfor example, about being unable to control alcohol or drug use consistentlyis a step clients can take toward recognizing what they need to do to overcome chemical dependency and related life problems. Encourage clients to take those steps, and give positive reinforcement for their progress. Remind them that they did not choose to become depressed or chemically dependent, but emphasize that they are responsible for stopping substance abuse and improving their lives. Accepting their illnesses will help them eliminate harsh self-judgments. Facilitate this process by educating them about the nature of chemical dependency and affective illness, and the process of recovery. Use lectures, films, tapes, or readings in addition to counseling sessions. Education, a vital component of treatment, often paves the way for clients to explore personal issues in the counseling process. 5. Help clients deal with anger. Some experts define depression as "anger turned against the self." Sometimes anger that has been chronically internalized also provides clients with a rationale for excessive drinking or drug use as well: "I'm pissed off, and booze is the only thing that calms me down." On the other hand, inappropriate anger and aggressive outbursts can have significant negative consequences. You can help clients deal with anger in several ways: ·

Encourage clients to explore attitudes and beliefs about anger and change them as needed.

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Evaluate the client's style of displaying and dealing with anger.

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Evaluate the effects of this style.

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Teach coping skills for dealing with anger.

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Cognitive strategies for coping with anger include learning to recognize and label anger; evaluating beliefs about anger; challenging angry thoughts with counterstatements; using fantasy, imagery, prayer, or meditation; evaluating risks and benefits of anger and methods of expression; and using slogans and positive self-talk (e.g., "This shall pass," "I'm in control," "Keep cool''). Verbal strategies include helping the client talk about angry feelings with the target of the anger or another person; talking about the situation, problem, or circumstances contributing to the anger; and making amends to people who have been hurt by the anger. Behavioral approaches include walking away from situations when the person feels intense anger and worries about losing control; redirecting anger into an activity; engaging in exercise or physical activity; writing thoughts and feelings in a journal or anger log; rehearsing ahead of time what to say in specific situations; using reminder cards with positive coping statements such as "Stay in control," "Talk about the problem," and so on, and doing an anger check at the end of each day to ensure that anger hasn't been suppressed and isn't being ignored. 18 Patients who carry around significant anger and rage from the past will need a lot of time and support in working through these feelings. Often this requires reaching the point where clients forgive others for the perceived or actual wrongdoing they experienced. Anger is a normal emotion and can be used as a positive force for facing problems or improving interpersonal relationships. Teach clients to guard against viewing anger only in negative terms. Very often anger can be the impetus that brings about positive change. 6. Help clients deal with grief. Look for clues to unresolved grief that may be contributing to depression. Many chemically dependent people experienced parental chemical dependency or psychiatric illness or both; broken homes; or traumatic experiences such as incest, physical or sexual abuse, rape, combat, and so on. They may be struggling with buried feelings of loss concerning these events. One alcoholic we know experienced frequent bouts of depression during periods of sobriety. Eventually, we learned that he had never fully grieved the death of his wife. This man tended to go on drinking binges whenever he felt sad and missed his wife. His depressive symptoms were most prominent around the anniversary dates of their wedding and her death and at certain family holidays. In counseling, he faced and resolved his grief, and thereafter was able to overcome his depression and remain sober.

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Through counseling, a depressed cocaine addict worked through the emotional pain she felt concerning her mother's chemical dependency. By taking part in a support group for adult children of the chemically dependent, she came to understand the connection between her intense anger, her "lost childhood," and her current difficulties with chemical dependency and depression. Her mood improved as she changed her self-defeating behaviors, such as visiting her mother during holidays, when her mother was usually drunk. Eventually, she learned to share her feelings with her mother, telling her that she would cut her visits short if her mother drank. Over time she learned to forgive her mother, work through her grief, and reduce her anger. Eventually, her depression lifted and she was able to stay off drugs. Some clients need to be shown how to handle the grief associated with lost relationships by learning to develop new ones. Of course, not all relationships can be replaced, but transferring emotional attachments may reduce depressed feelings. In many cases, people who give up their dependence on chemicals experience a sense of loss. So, too, do those who lose their jobs or who are forced to change careers. Depression can rob people of their ability to function; this severe change in status can trigger overwhelming feelings of loss and grief. Any of these situations may arise in counseling sessions. 7. Help the client see the connection between feelings and behaviors. Point out the relationship between depression and behaviors. For example, some individuals feel depressed because they are alone and have no significant interpersonal relationships. They have trouble starting and keeping intimate relationships because they are shy or overdemanding, or they tend to overwhelm the other person with their needs. Such behavior can contribute to depression. Changing Thoughts and Beliefs Researchers have noted that along with depressive feelings, depressive thoughts play a significant role in depression. By changing some of these negative thoughts and the beliefs and assumptions that underlie them, clients can decrease depressive feelings and improve their overall level of functioning. They can also improve mood by increasing positive thinking. 19 Cognitive-behavioral approaches have been used extensively with depressed people and with those who are chemically dependent; they also work with those who have both disorders. They help clients modify

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maladaptive thoughts, assumptions, or beliefs and teach them specific problem-solving or adaptive cognitive skills. 20 According to experts in cognitive treatment, the common assumptions that underlie a person's automatic thoughts or images (also known as cognitions) predispose some individuals to excessive depression or sadness. Examples of these assumptions include the following:21 ·

In order to be happy, I have to be successful in whatever I undertake.

·

To be happy, I must be accepted by all people at all times.

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If make a mistake, it means that I am inept.

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I can't live without you.

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If somebody disagrees with me, it means he doesn't like me.

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My value as a person depends on what others think of me.

Cognitive interventions are aimed at helping clients understand the relationship between thoughts, styles of thinking, feelings, and behaviors.22 Clients learn to monitor thought patterns so they can identify and label faulty or distorted thoughts and practice altering them. One technique, called "countering," uses logic to expose and change distorted thoughts. These are the principles for countering:23 1. Counters must be the direct opposite of the false belief. 2. They must be believable statements of reality. 3. Clients should develop as many counters as possible. 4. They must be created by the client (with coaching from you, the counselor). 5. They must be concise. 6. They must be stated with assertive, aggressive, and emotional intensity. Depressed people frequently overlook their own positive efforts or ignore their successes. You will therefore want to remind clients to give themselves positive reinforcement for their work. Use "live data" from counseling sessions or review the client's thoughts between the sessions. When possible, identify trends or patterns in the person's thinking as well as the specific individual thoughts. Following are common problematic patterns of thinking identified by Beck, Ellis, Burns, and other experts in cognitive-behavioral treatment.24 A client's particular cognition may represent more than one type of cognitive distortion. 1. Black-and-white or dichotomous thinking. Depressed patients often see

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things in terms of "all or none," "right or wrong," "yes or no." They exhibit little flexibility and are unable to see alternatives in a situation. One depressed alcoholic told us, "I hate AA. I can't get anything out of it.'' When we explored this statement, however, we discovered that this client did not hate AA. In fact, he enjoyed many aspects of it, especially the friendliness and helpfulness of AA members. What he hated was his perceptionan incorrect onethat he would have to tell his story "to a bunch of strange people.'' However, when he learned that doing so was an individual decision based on such factors as the length of sobriety, willingness to share, and so forth, he changed his thinking. As a result, he learned to use AA more effectively. A woman who overate during the holidays gained a few pounds. She told herself, "Well, I've blown my diet completely." Even though she had lost more than thirty pounds in the past year, she believed this one mistake indicated that she was a total failure. She felt better when she learned to challenge the notion that she had completely blown her diet and to tell herself, "I made a mistake and ate too much over the holidays. I've been doing well up to this point, so I'd better catch myself and get back on my diet program now." You can help clients overcome such cognitive distortions by having them evaluate events on a continuum and think in terms of "shades of gray." 25 Show them how to evaluate events or situations in terms of degrees, rather than on an all-or-none basis. 2. Seeing things as worse than they are (awfulizing). Depressed people frequently make mountains out of molehills. Often they pay too much attention to a single negative detail, causing them to evaluate the entire situation as negative.26 One of our clients reported feeling upset because he'd had a flat tire and was fifteen minutes late for his counseling session. He thought, "What a terrible thing to happen. I'm going to have a rotten day." We worked to expose his irrational thinking, encouraging him to challenge his original thought and change it to a different one: "It's unfortunate I had a flat tire. But I fixed it with no difficulty, and I'm not going to let this minor inconvenience ruin my day. It isn't the first nor will it be the last flat tire I will have. It's really no big deal." In another case, a client and her husband discussed their marriage. Although he gave her a lot of positive comments and supportive feedback, he did make one critical remark: that she worried too much. For days afterward, she obsessed about this one comment. She felt bad about herself. In therapy she learned to stop dwelling on this one negative remark and to balance it against the

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many positive things her husband had said. 3. Overgeneralizing. Patients often use one experience to make broad generalizations about life. For example, one client recently bought the wrong parts for her husband's car. In session she called herself "stupid." "I just can't do anything right," she lamented. "I'm a washout.'' In evaluating this experience and her related thoughts, she learned to see that making a simple mistake did not justify such a harsh conclusion. Another client was turned down for a job. He concluded, ''I'll never get a job. No one wants to hire me." We worked with him to show that such a conclusion was unfounded. By exposing the faulty logic of overgeneralization, you help clients see their situations more realistically. Be alert for the use of such words as never or always, which are red flags warning that the client may be generalizing. 4. Expecting the worst outcome (catastrophizing or magnification).Depressed individuals often look at the possible outcome of a situation in negative terms, frequently telling themselves the worst possible thing that can happen will happen. For example, after working hard at staying sober for seven months, one of our clients talked himself into drinking two beers. He thought, "Okay, I blew my recovery. My AA friends and counselor are going to think poorly of me and tell me to come back only when I'm ready to stop drinking." To his amazement, though, he found that others were very supportive of him. They helped him develop a stronger recovery program to minimize the damage caused by his lapse. The terrible outcome he expected did not occur. In another case, a wife in charge of the family spending went over budget one month. She tortured herself with the thought, "Walt is going to be furious at me for screwing up the finances." She became anxious and depressed as a result. In therapy, she learned to challenge that thought and change it to another one: "Why should he be angry with me? I didn't do anything wrong. Billy was sick and had to go to the doctor, and the transmission blew out on the car and had to be fixed. These things happen to everyone. They're no one's faultcertainly not mine. Once I explain what happened, I'm sure Walt will understand." Review with your client all of the evidence and all of the real probabilities of a situation. Focus on evidence indicating that the worst case may not happen and emphasize the possible positive outcomes 27 5. Disqualifying the positive (selective abstraction). When depressed, people tend to overlook or downplay the positive side of things. They refuse to give themselves credit for what they've accomplished, focusing instead on

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their failures or personal weaknesses. A client in our treatment program was praised by his peers for the excellent leadership role he had assumed during a community crisis. He quickly dismissed the praise and dwelt on some minor thing that he hadn't done. Another client presented his list of "pros and cons" (positive and negative traits) to his therapy group. He identified eight negative traits but only one positive trait. His group was baffled because they thought very highly of him; in their evaluation, they had listed the many positive traits they had observed in him. Work to counteract this type of cognitive distortion by helping clients focus on present and past successes. Encourage them to identify personal strengths. In group sessions, elicit realistic feedback from other members. A personal inventory, as suggested in Step Four of the Twelve Steps, helps people evaluate their strong points. Having them keep a daily journal of positive experiences works well too. Ask them to write down at least one positive event that occurred during each day, no matter how small or insignificant the event appears to be. 6. Jumping to conclusions. Depressed clients often jump to incorrect or negative conclusions without having a firm grasp of the facts. Sometimes, too, they assume that things will turn out badly in the future (a problem known as "fortune-telling"). One client talked herself into feeling depressed because she thought her husband was angry with her. She based this conclusion on her observation that lately he hadn't seemed "his usual fun-loving self." In another case, a man felt bad because a friend never returned a phone message left on his answering machine. From this, he concluded that his friend "doesn't want to have anything to do with me.'' You can help clients overcome this type of faulty thinking by examining the facts and details of a situation. Remind them that it is impossible to read other people's minds and know what they are really thinking in a situation. Encourage them to conduct periodic reality checks. In the examples cited above, the first client got the facts simply by asking her husband if anything was bothering him. She learned that he wasn't angry but was preoccupied with a work-related problem. In the second example, the man found out that his friend's answering machine was broken, and that the friend was actually very glad to hear from him. In both cases, the people felt better when they discovered that the conclusions they had reached were incorrect. 7. Emotional responses. In these cognitive distortions, people assume that their negative emotions reflect the way things really are. One of our clients felt overwhelmed by several problems he was experiencing and concluded

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that his problems were completely insolvable and that he was inadequate. To feel better, this client had to accept that he was not an inadequate person because he was struggling with some problems. Another client judged herself as "inadequate and a worthless nobody" because she couldn't help a family member take care of a serious problem. She learned that it wasn't her fault that her family member wouldn't solve this problem. She also was encourageed to see that her efforts to help were important, regardless of the outcome of the situation. Work with clients to overcome such distortion by underscoring the difference between "feelings," ''self-judgments," and "personality characteristics." Feeling a certain way doesn't necessarily reflect a permanent part of the person's personality. 8. "Should" or "must" statements. Patients create many rigid rules for themselves that dictate their feelings and behaviors and can put them at risk of depression. These rules usually contain the words should or must. Help the client identify, challenge, and revise these "should" rules. For example, if the client's rule is "I should always like NA or AA meetings," revise it to "Some meetings are likely not to be interesting to me. I can't always like them. That would be unrealistic." If a client says, "I should visit my parents every week," help him change it to something like this: "I'll visit Mom and Dad as much as I can, but it just isn't possible to visit every week. I can call them during the weeks when I don't visit.'' The client who believes she should always feel good about her spouse and kids can revise this to "It's impossible to always feel good about your mate or children. Everyone gets irritated with people they care about. That's only human nature." The client who believes she should never get angry at others can say, "It's normal to get mad sometimes. It may be a signal that there's a genuine problem that we need to work out." 9. Labeling and mislabeling. Often clients base a negative self-image on mistakes they have made. Instead of simply saying, "I made a mistake," they tend to say, "I'm a total failure, a complete loser." One minor experience can cause clients to paste a permanent negative label on themselves. Another common example among people in recovery is to say, "I relapsed, so I'm a terrible person." In therapy such clients need to learn an alternative. They can say instead, "I let my guard down and drank. I made a mistake. I'd better talk this over with my counselor or sponsor and learn from it to prevent it in the future. I feel bad this happened, but it doesn't make me a terrible person or a failure." 10. Personalization (self-reference). Some clients take the blame for negative events for which they are in no way responsible. For example, a father blamed himself for his son's failure to make good grades in school. He told

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himself, "I must be a lousy father if my son does poorly in school." Through counseling he learned to challenge this distortion, saying, "It's unfortunate my son did not do well this term in school. I'll talk with him and his teacher and try to figure out ways to help him bring his grades up next term. Help clients appraise situations realistically to discover the possible causes of negative events. Show them they need not assume responsibility for all that goes wrong. Experts in cognitive-behavioral treatment have developed a number of written materials outlining practical ways to identify and change faulty thoughts, assumptions, and beliefs. Many of these strategies apply to the treatment of depression and chemical dependency in a concrete and practical way. Changing Behaviors, Relationships, Interpersonal Style, and Lifestyle Other ways you can help people with depression and chemical dependency include facilitating change in behaviors, interpersonal relationships, interpersonal style, or lifestyle. These are some of the options available for intervention in these areas. 1. Help clients identify things they want to change. Planning and implementing a plan for change is easier if your clients identify the specific problems or behaviors they want to target or the skills they need to acquire. Sometimes, in cases of depression, behavior has to change before mood can improve. Counsel clients to work for change, even when they don't feel like doing so. Simple activitiesexercising, cleaning the house, calling a friend on the telephone, finishing the monthly budgetmay lessen feelings of depression. Successful experiences with concrete behavioral tasks can be effective in breaking the vicious cycle of demoralization, passivity, avoidance, and self-disparagement seen in severely depressed people. 28 As your clients become more active, they will find that taking action becomes easier and more enjoyable, especially if they experience positive results. Prepare patients to complete some behavioral tasks by having them first imagine going through each discrete step necessary to complete the task. In cases where the client is highly anxious, the client can practice tasks that involve interaction with others in role-playing exercises. One of our clients agreed to attend AA meetings, but she stated that she felt very uncomfortable going to a "strange meeting and not knowing anyone." She decided to ask a co-worker, a woman who openly acknowledged her chemical dependency and involvement in AA, if she would take her to the

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meeting. In role-playing sessions with her counselor, the client rehearsed the act of approaching her co-worker and asking for her help. Doing so helped her gain the courage she needed to carry out the task. Several positive developments resulted. The client entered AA, which helped her maintain sobriety. She also acquired a crucial social skill in making friends with another recovering female alcoholic who "knew the ropes." Dealing successfully with obligations or problems can also have a positive impact on mood. Some clients berate themselves for not completing tasks. You can help them prioritize and follow through on such tasks and, in so doing, help them achieve improvement in mood. Lewinsohn and colleagues, who designed the Coping with Depression course, recommend a "self-change" plan involving seven steps: 29 ·

Pinpoint or specify the behavior or thought to change or the new skill to learn.

·

Gather information to establish a baseline for the behavior.

·

Identify circumstances that exist before a given behavior occurs.

·

Identify consequences that happen after the behavior occurs.

·

Set attainable goals.

·

Establish a contract identifying rewards for accomplishing steps toward goals.

·

Choose appropriate reinforcers.

Work with clients to assess realistically their personal strengths and accomplishments. The personal inventory Steps of AA, Steps Four and Ten, provide one mechanism for doing so. When possible, also discuss events that occur between counseling sessions. Such strategies help depressed addicts identify and acknowledge positive attributes, which they are otherwise prone to discount or ignore. The feelings of powerlessness, guilt, and shame that are symptoms of depression rob your clients of self-esteem. Increase their feelings of selfworth by offering positive feedback, helping them set and work toward achievable goals, and looking for opportunities to provide them with successful experiences. Using specific behavioral tasks is a helpful approach. 2. Help the client change interpersonal relationships or interpersonal style. Depression is more likely to persist in chemically dependent individuals whose personal relationships have been disrupted.30 Identify realistic steps clients can take to improve current relationships. The "making amends" Steps of AA and NA, Steps Eight and Nine, are a good way for addicts to

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undo some of the damage caused by their chemical dependency. However, in the early phase of recovery, don't push too hard. Start simply by inviting clients' significant others to participate in recovery sessions on education, counseling, self-help, and so on. Depressed people often feel alone in their suffering. They tend to withdraw and isolate themselves from other people. Help them increase their interaction with others. Emphasize the importance of taking an active role in social and family relationships. Encourage them to attend or plan family and social events. You'll no doubt hear them complain that they "don't feel like it." Underscore the idea, though, that when the behavior changes, so do the thoughts and feelings. Involving families in treatment sessions increases your clients' motivation to interact with other people or to complete assignments. What's more, these significant others can provide valuable feedback not just to the patient, but to you as well. Family counseling has the added benefit of improving the quality of family communication and interaction, which increases the chances for a happy outcome. To improve existing relationships or develop new ones, some clients may need help in learning new interpersonal skills. These skills may include resolving interpersonal disputes or conflicts, increasing assertive behaviors, starting and maintaining conversations, giving and receiving criticism, asking for help or support, providing help or support to others, learning appropriate ways of self-disclosure, and improving communication skills. Improving relationships gives clients a better chance at meeting their needs for love, intimacy, and friendship. 3. Help the client make other lifestyle changes. Authorities on depression emphasize the importance of participating in pleasurable activities. Research shows that when depressed clients are socially or physically inactive, they report an overwhelming number of self-debasing and pessimistic thoughts. 31 Consequently, leisure counseling aimed at developing new hobbies and recreational activities can help, as can the cognitive interventions discussed earlier. Work with clients to identify and schedule activities they will find enjoyable. Show them how to develop and follow a weekly activities program. (Remember to include AA- or NA-related events, such as meetings, special activities, reading recovery literature, and so on). Make sure clients know about any local clubs and organizations that offer social and recreational events designed for people in recovery. You may have to prod the client gently to participate. If necessary, call on other AA or NA members for assistance. They can help by driving your clients to functions

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or by providing company and support until your patients feel comfortable and show more independence. Be flexible; clients seldom follow such schedules completely, especially in the early stages. Whatever happens, support their efforts. Other lifestyle interventions include increasing physical exercise and activity, learning relaxation techniques, and developing strategies for balancing obligations ("shoulds") with desires ("wants") 32 If a client's life is filled only with obligations, the chances of deriving pleasure decrease. Help clients examine their lifestyle to find a better balance between these "shoulds'' and "wants." Setting goals is another helpful lifestyle intervention. These goals, which can relate to any area of functioning, may be short-term, intermediate, or long-term. In any case, the goals should be realistic and attainable; otherwise the client is likely to feel more depressed if they are not achieved. Encourage clients to reward themselves not just for achieving their goals, but for making the effort. Chemical Dependency Rehabilitation Programs Depressed clients can benefit from traditional residential and outpatient nonresidential programs, so long as symptoms of depression are under control and the individuals are not actively suicidal. Pay close attention to their mood while they are enrolled in such programs. In addition to focusing on their recovery from chemical dependency, treatment can also be aimed at improving their ability to cope with depression and related problems. You and the other members of the counseling staff should make sure, however, that clients do not focus solely on their depression and ignore the problem of alcohol and drug use. As we noted earlier, clients for whom antidepressants have been prescribed may be told by others in recovery to stop taking their medications. Monitor compliance carefully, and devote time to exploring your clients' attitudes about the use of prescription medications. Psychiatric Hospitals Many clients with depression and chemical dependency end up in a psychiatric hospital, voluntarily or involuntarily. Recently the trend has been toward brief stays in inpatient acute-care psychiatric hospitals. The primary goal in such settings is to stabilize the mood disorder. In some cases, however, detoxification is needed as well. Pay attention to the possible relationships between mood problems and the use of alcohol or other

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drugs. Patients should be shown how continued use of alcohol or other drugs can complicate recovery from depression and can interfere with the efficacy of medications. The particular balance between focusing on mood problems and chemical dependency problems will, of course, depend on the clinical presentation of each client as well as the reason for hospitalization. For example, clients who come to the hospital under an involuntary commitment often resist treatment at first. The first step in such cases is to help the client accept the fact that hospitalization is necessary. Then explain the specific symptoms or problems that led to the admission. In some instances, after the mood is stabilized, clients may need to be referred to a chemical dependency rehabilitation program, therapeutic community, or halfway house for more intensive focus on the addiction. Again, the specific referral depends upon the clinical presentation and problems of the individual. Clients with severe personality psychopathology in addition to depression and chemical dependency should be evaluated for possible referral to a longer-term residential facility, such as a therapeutic community. Halfway House and Outpatient Programs Some depressed chemically dependent people benefit from halfway house programs, particularly if they lack a healthy social support system. Following completion of the rehabilitation or halfway house program, aftercare plans should include referral to outpatient counseling and a Twelve Step program. Counseling or referral services dealing with occupational or educational goals can also help clients feel better about themselves. Counselors in a halfway house or outpatient clinic can focus on any of the issues discussed in this chapter that relate to the individual client. One particular area of emphasis is helping clients learn to deal with depressive episodes without resorting to alcohol or drugs. Since in many cases depression can recur, teach clients to identify the signs of onset so they can seek help before the episode becomes disabling. In chapter 11, we will address issues pertinent to relapse in greater detail. Self-Help Programs These programs offer the depressed addict an excellent context in which to deal with many of the issues that pertain to his or her individual situation. Such groups include AA, NA, CA, or the other self-help programs devoted to chemical dependency; special groups such as Double Trouble, Mentally Ill Substance Abusers (MISA), or Substance Abusing

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Mentally Ill (SAMI), which address the needs of those with dual disorders; and support groups for individuals with mood disorders, such as depression or bipolar illness. The fellowship available in self-help groups increases social interaction and reduces loneliness. Twelve Step programs offer a structure for dealing with many of the interpersonal and psychological complications of dual diagnoses. As some of these conflicts are reduced or resolved, mood and functioning often improve. Medications Some chemically dependent individuals have depressions that result from biological factors rather than from troubling events in their lives. These endogenous depressions often respond well to antidepressants, as do severe depressions from other causes. Such medications are in an entirely different class from tranquilizers and have little or no potential for abuse. People with a dual diagnosis of chemical dependency and depression who are candidates for antidepressants should not be made to feel guilty about their need for medication. You or the physician should encourage these patients to discuss with you any incidents in which others tell them to stop taking their prescriptions. It sometimes happens that well-meaning therapists or overzealous people in recovery will claim that recovery means use of all drugs must cease. The facts are different; AA fully recognizes that some of its members will benefit from medications prescribed for psychiatric or medical disorders. 33 Several types of antidepressant medications are available to treat depressive illness: 1including imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Pamelor), and desipramine (Norpramin). Usually these must be taken at the appropriate dose for at least ten days before mood begins to lift. As patients continue to take these medications, the antidepressant effects grow. Unfortunately, these medications may also produce unpleasant side effects that some clients have trouble tolerating: dry mouth, blurred vision, dizziness on standing, sexual dysfunctions, and difficult urination. Many of these side effects, however, can be mitigated by adjusting the dose. If you notice side effects occurring, notify the treating physician. Over time, most individuals who respond to the TCAs become tolerant of any side effects; they are happy to accept the minor discomfort of dry mouth if it means relief from the agony of depression.. Tricyclic antidepressants (TCAs),

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2such as phenelzine (Nardil) and tranylcypromine (Parnate). Although these antidepressants appear to work a little faster than the TCAs, they have a major drawback. Clients taking MAOIs must maintain a special diet in which they avoid foods that contain tyramine, such as aged cheeses (cheddar, for example), beer, wine, sherry, liquors, sausage, pickled or smoked meats or fish, figs, banana-peel fiber, and fava or broad beans. Tyramine may interact with MAOIs to produce dangerous elevations in blood pressure, putting the patient at risk of a hypertensive crisis. If your clients are taking MAOIs, reinforce the importance of sticking closely to the recommended diet. In addition, these medications may cause such side effects such as headaches, insomnia, weight gain, and sexual dysfunction.. Monoamine oxidase inhibitors (MAOIs), 3. Other antidepressant medications such as fluoxetine (Prozac) or sertraline (Zoloft), which are classified as serotonin reuptake inhibitors. Like other antidepressants, these medications may produce side effects such as agitation and sleep disturbance. They stay in the system a very long time; if a medication change is needed, a few weeks will be needed for a "washout" period. Certain antidepressants will require that blood levels be monitored to ensure that the client is taking the medication and that the appropriate therapeutic level has been reached. Another consideration clients must be made aware of is that the combination of alcohol and medications is highly unsafe. Alcohol can interfere with the efficacy of antidepressants and alter the level of medication in the bloodstream. The length of time that a client remains on an antidepressant medication depends on the client's history and on the current clinical profile of the depression. Generally, clients should continue to take antidepressants for four to six months after symptoms begin to remit. Those who have a history of recurrent depression (three or more episodes) should remain on maintenance medication in order to reduce the risk of future relapse. Monitor medication compliance closely, because a significant number of clients stop taking their medicine and do not comply with the recommended dosage schedule. As a result, depressive symptoms often return. Be aware of the need to continually evaluate the risk of suicide in depressed clients, especially those taking medications. Some clients may deliberately try to overdose. If your client reports taking an overdose of antidepressants, send him or her immediately for an emergency medical and psychiatric evaluation. If the client refuses, commit him or her involuntarily or work with the family to initiate a commitment.

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Dysthymia If one views the affective disorders as a spectrum, dysthymia appears on the lower end because its clinical profile involves less intense symptomatology, although it is more chronic in nature than major depression. In some ways dysthymia appears similar to major depression, but there are differences. Assessment Criteria According to the specific criteria for this disorder include the following: DSM-III-R,*34 1. The patient is in a depressed mood for most of the day, more days than not, as indicated by either subjective account or observation by others, for at least two years. 2. The patient experiences, while depressed, at least two of the following: ·

poor appetite or overeating

·

insomnia or hypersomnia

·

low energy or fatigue

·

low self-esteem

·

poor concentration or difficulty making decisions

·

feelings of hopelessness

3. During a two-year period of the disturbance, the patient is never without the symptoms in (1) for more than two months at a time. 4. There is no evidence of an unequivocal major depressive episode during the first two years of the disturbance. 5. The patient has never had a manic or hypomanic episode. 6. The depression is not superimposed on a chronic psychotic disorder. 7. It cannot be established that an organic factor initiated and maintained the disturbance. Assessment Issues As with major depression, clients with a dysthymic disorder experience low mood and loss of interest or pleasure in all or almost all usual activities. There is also a sense of sadness and of "feeling blue" or "down in the dumps." Dysthymia is a chronic disorder with symptoms persisting for a Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised [ DSAI-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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period greater than two years, whereas symptoms of major depression may be present for as little as two weeks to qualify for a diagnosis. Compared to major depression, however, the depressive symptoms and the impairment in psychosocial functioning seen in dysthymia tend to be less severe. The client with a major depression may experience severe weight loss, while this symptom is not typically seen in dysthymia. Dysthymic clients often are chronic users of both inpatient and outpatient mental health or chemical dependency treatment services. A review of past treatment experiences will help determine appropriate treatment goals. Unlike with major depression, with dysthymia a precipitating event can seldom be identified as the cause of the symptoms. Antidepressant medications may be used for the client with dysthymia, although typically they are more appropriate for those whose symptoms of major depression do not resolve after a prolonged period of abstinence from alcohol and other drugs. Be sure to obtain a history from your clients and their families. Since a hallmark of dysthymia is that it persists for at least two years, an accurate picture of a client's mood and functioning for at least that period is required. Children with depression are predisposed to develop dysthmyic disorder. Such children react negatively to praise, frequently exhibit testing behaviors, and do not perform well in school. As with other diagnoses, consultation with a psychiatrist or psychologist is recommended to assist in establishing diagnosis and treatment goals. Keep in mind that depressive symptoms are often present with the chemically dependent in the early weeks and months of recovery. If these symptoms are not part ofa dysthymic disorder, they will, in time, subside. Counseling Issues Dysthymic clients may be admitted into the treatment system as a result of increased drinking or drug use, increased depression, or a suicidal threat or gesture. They may need to be detoxified before they are in any shape to benefit from further treatment. After detox, and once clients are relatively stable, they can be evaluated for possible referral to a chemical dependency rehabilitation program. Although dysthymic symptoms usually persist beyond detoxification, such clients still can benefit from a treatment program for chemical dependency. Be aware that these are generally difficult clients to work with, in part

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because they have negative outlooks on everything. They frequently predict their own self-defeat, uttering such statements as ''This isn't going to help me," "I'm a loser," or "I'm never going to change." Characteristically they appear poorly motivated and hopeless about the future. As a result of avoiding constructive activities, they tend to show low levels of energy and poor investment in activities or relationships. They frequently present themselves as being easily overwhelmed with problems. Helping them identify and work on solvable problems is one strategy that helps them feel a sense of control. Their problems sometimes have to be broken down into manageable parts; the Substance Abuse Problem Checklist mentioned in chapter 2 (page 23) can be a very useful tool in helping these clients identify specific problems. Some counselors may feel drained or experience burnout when dealing with these clients because improvement in their mood and functioning occurs so slowly. Similarly, some counselors may feel angry that the client appears passive, doesn't seem to be working at treatment, minimizes positive changes that do occur, or doesn't respond to efforts to help him or her. It is not unusual for caregivers to become overwhelmed by the same feelings of helplessness and hopelessness shown by the client. You may need to adjust your expectations and your approach to prevent feelings of frustration or inadequacy. Be realistic: expect progress to be slower. Any of the counseling issues that apply to major depression may come into play with these clients as well. The information about halfway house, outpatient, and self-help programs is also relevant to the chemically dependent individual with dysthymic disorder. Again, we stress the need for the counselor's expectations to be realistic and the need for the counselor to be supportive of any successful experiences such clients may have. We encourage the use of cognitive and behavioral counseling approaches as well as Twelve Step programs. Active counseling approaches, such as assigning homework tasks or rehearsing specific behavior changes through role-playing, help clients take an active role in changing their behavior. Written journals and cognitive exercises that involve tracking and changing negative or depressing thoughts can also be useful. Assessment of Suicidal Risk People with chemical dependency are at high risk of suicide. The presence of depression increases the danger enormously. Reports indicate that suicide accounts for between 5 percent and 27 percent of all deaths among

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substance abusers. What's more, between 15 percent and 25 percent of all suicides are committed by the chemically dependent. 35 One recent study found that 58 percent of suicides involved chemical dependency.36 A report by the National Institute on Alcohol Abuse and Alcoholism states that "the chemically dependent who attempt suicide form a significant part of the population that eventually succeeds in committing suicide."37 This is particularly true for chemically dependent women, whose rate of suicide completion is much higher than that of the general population. Suicide is also a factor in depression; in fact, many experts feel that depression underlies the majority of suicides in this country. Approximately 15 percent of people with severe depression commit suicide. Although statistics on the rate of suicides among people with the dual diagnosis of depression and chemical dependency are hard to find, it is likely that the numbers would be higher than those seen in either diagnosis alone. People usually give definite warnings of their suicidal feelings or intentions.38 These signs can be very obvious. The person may directly state, "I'm going to kill myself," or the signs may appear as subtle changes in behaviors. Potential suicides may isolate themselves from others and withdraw from usual activities. They may draw up wills or give away valued possessions.39 Often people use alcohol or other drugs to overcome their inhibitions, to work up the nerve to attempt suicide, or to increase the effects of the drugs taken in an attempt to overdose. In some cases, people drink so much alcohol or take such high quantities of drugs that either they don't know what they are doing at the time of the attempt or are unaware of the full implications of their actions.40 Suicide attempts may be premeditated or impulsive. The chemically dependent are prone to impulsive actions arising from impaired judgment. As a result, counselors can't always predict if a given client is a suicide risk. You should be familiar with the following indicators that place the client at higher risk for suicide:41 ·

a history of previous suicide attempts; 80 percent of those who kill themselves tried to do so at least once previously

·

successful suicide by a role model (e.g, a parent or other relative, a friend, or a celebrity)

·

loss of a close interpersonal relationship

·

other major physical or psychosocial stressors (a crippling physical disability, loss of a job, financial crisis, etc.)

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·

previous psychiatric illness

·

depression accompanied by feelings of hopelessness

Be direct and caring when you ask about recent or current thoughts of suicide. If clients acknowledge suicidal thoughts, ask if they have a concrete plan to act on these thoughts. Discuss specific details of the plan: ·

the method of suicide

·

when they intend to make the attempt

·

where they will do it

·

why they want to end their lives

·

what impact this action will have on others

·

whether anything such as strong religious beliefs or family attachments would prevent them from carrying out the plan

Inquire whether the clients have settled their personal affairs (for example, made a will or given away important personal possessions). If the client has attempted suicide before, find out how, when, where, why, and what the outcome of treatment was, if any. If you spot any indication that clients are at risk for suicide, particularly if they have a plan that seems especially lethal, get an appropriate consultation immediately. Take special precautions with clients who are currently suicidal to protect them from their destructive impulses. Sometimes this means psychiatric hospitalization. If such clients refuse admission, be ready to pursue legal means to protect them from self-harm. You will need to be familiar with local laws and procedures governing evaluation for commitment. Be sure, too, to advise families of clients' suicidal behavior. Enlist their involvement in the suicide prevention plan, especially if the family appears likely to be helpful and supportive. Summary Major depression and dysthymia are two mood disorders prevalent among people with a coexisting chemical dependency. Of all the dual disorders, depression with substance abuse seem to respond comparatively well to treatment. A variety of pharmacologic and psychosocial treatments, especially cognitive-behavioral and interpersonal psychotherapy, have proved effective in dealing with depression; generally these treatments appear to be useful for clients who also are chemically dependent.

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Suicide is common in substance abusers and people with depression; those with both disorders are at an even higher risk. Counselors should regularly assess the risk of suicidality in all such patients by asking direct questions about suicidal ideation and any plans for suicide. Interventions to prevent suicide include involuntary hospitalization and alerting concerned family members about the potential risk.

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Chapter 7 Bipolar Disorder and Chemical Dependency An Overview Bipolar disorder, sometimes known as manic-depressive illness, is an affective disorder frequently linked with chemical dependency. This disorder may involve a manic episode, a depressive episode, or both (referred to as a ''mixed state"). 1 Bipolar illness is a cyclical mood disorder with alternating episodes of mania and depression. Onset of the illness usually occurs before age thirty, although new cases can develop after the age of fifty.2 In most cases, the first episode involves a swing into the manic state. Often a brief depression follows after the mania has resolved; sometimes, though, subsequent episodes of mania may occur after an intervening period of normal mood (i.e., without a dip into a depressed state first). Some individuals experience a "mixed" state, in which both manic and depressed syndromes are intermingled or rapidly alternate every few days. About 10 percent to 20 percent of people with bipolar illness suffer from rapid cycling, involving four or more cycles of mania (or hypomania, a somewhat milder manic episode) and depression per year. Early research into this dual diagnosis suggested that there was increased alcohol consumption during both the depressive phase and the manic phase. More recently, however, studies have demonstrated that excessive alcohol use appears to occur predominantly during mania, and that there is a tendency to shun alcohol during the depressed phase of the illness.3 Investigators have also demonstrated that although both bipolar disorder and chemical dependency are familial diseases, people inherit their predisposition to the disorders via separate genetic pathways.4

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Prevalence of Bipolar and Chemical Dependency Disorders Rates of chemical dependency are high among individuals with bipolar disorder. The ECA survey found that more than 60 percent of individuals with a bipolar disorder met lifetime criteria for chemical dependency: 47 percent met criteria for alcohol abuse or dependence disorders, and 41 percent met criteria for drug abuse or dependence disorders. 5 Goodwin and Jamison's extensive review of clinical studies indicates that the prevalence of alcoholism among bipolar clients ranges from 18 percent to 75 percent.6 Studies of different client populations, conducted over the past seventy years using a wide variety of diagnostic criteria, consistently found elevated rates of alcoholism in clients with bipolar disorder. For example, in 1921, Kraepelin reported a 25 percent rate of alcoholism in manic-depressive (bipolar) clients. Parker and colleagues reported in 1960 that 33 percent of manic-depressive clients were alcoholic.7 In 1970, Freed reported that 65 percent of manic-depressive clients abused alcohol during the manic phase of their illness.8 More recent clinical studies indicate high rates of this dual diagnosis, particularly among individuals heavily using cocaine or other stimulants. Estroff and colleagues found that 75 percent of bipolar manic clients abused alcohol.9 Studies conducted by Mirin and Weiss found that 16 percent to 23 percent of cocaine abusers met criteria for bipolar or cyclothymic (a milder form of bipolar) disorders;10 in another group of cocaine-abusing patients, Nunes and colleagues found the rate to be 30 percent. 11 Individuals with bipolar disorder are more likely to use cocaine during the manic phase, although they may also use the drug to alleviate dysphoria during the depressed phase of the illness. Relationships Between Bipolar Disorders and Chemical Dependency The studies cited indicate higher rates of chemical dependency among individuals with bipolar disorders and higher rates of bipolar disorders among individuals with chemical dependency, compared to the general population. Having one of these disorders increases the odds of having the other. The manic and depressive symptoms associated with bipolar disorder can be caused or exacerbated by acute or chronic use of alcohol or other drugs. A biologically vulnerable individual, for example, may experience a first manic episode following the use of stimulant drugs. Hallucinogenic drugs such as LSD or PCP have been associated with manic-depressive psychoses in several studies.12

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The use of alcohol and other drugs can also partly or totally mask symptoms of affective illness. Symptoms of depression or bipolar disorder may emerge after a period of detoxification or total abstinence from chemicals. One study reported that clients with alcoholism and bipolar disorder experienced an average of 203 days of illness prior to beginning treatment, compared to only 37 days for clients who did not have coexisting alcoholism. 13 By the same token, a bipolar affective disorder can affect a person's use of alcohol or other drugs, since some clients are more likely to use alcohol or other drugs in order to medicate symptoms of their illness. What's more, the course of affective illness or recovery can be modified by chemical dependency. For example, individuals with rapid-cycling bipolar disorder have a poorer prognosis. The use of alcohol or other drugs is also likely to increase during the "switch" from one phase of the illness to the other. 14 Bipolar and chemical dependency disorders may also develop independently and may be unrelated to each other. An individual can experience an episode of mania or depression months or years after undertaking recovery from alcoholism. An individual recovering from bipolar disorder can become dependent on alcohol or other drugs long after the onset of the psychiatric illness. Characteristics and Effects of Bipolar Disorders Clients with bipolar disorder and chemical dependency represent a diverse group of individuals with a variety of clinical presentations. Some clients experience major manic and depressive episodes; others experience primarily mania with less depressive symptomatology; and still others experience primarily depression, with less intense manic symptomatology. The number, frequency, and intensity of episodes may vary from one client to the next. Up to 20 percent will have a rapid-cycling form of the illness in which four or more episodes are experienced per year. 15 Bipolar disorders affect many areas of the client's functioningphysical, emotional, social, interpersonal, familial, sexual, occupational, and spiritual. Specific effects depend on the duration and severity of the episode, the duration and severity of the chemical dependency, and the coexistence of other physical or psychiatric illnesses. Whether singly or in combination, the presence of mania and the effects of substance abuse can impair judgment, reduce impulse control,

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and worsen symptoms. The individual with a bipolar illness may therefore be at risk for suicide. Later in this chapter, we will discuss the assessment of suicidality and strategies for intervention. Case History: Dan Dan is forty-nine years old, married, the father of four children (one of whom, a son, still lives at home), and the grandfather of three. He has worked as a home remodeler for the past twenty-four years. His many talents have provided his family with a very good living, and he has been able to work for himself during most of this time. Dan is an alcoholic with bipolar disorder who completed a rehabilitation program for alcoholism thirteen years ago. He entered the program as a result of his arrest for driving through a red light. His blood alcohol level was 0.27 at the time. Dan's drinking pattern varied. During some periods, he would have two to four drinks several days a week. Other times he would drink every day, sometimes polishing off a fifth of scotch or more. His tolerance for alcohol was quite high, although he reported that it had diminished in the latter years of his drinking. He also had many blackouts and often went to the bar early in the morning for an eye-opener to help stop the shakes he sometimes experienced. Dan's drinking caused many problems for him and his family. He lost several jobs when he failed to show up because of his hangovers. Sometimes when drinking he became nasty and hostile toward his wife, Linda, and his children. Many times, Dan blew the family income at the local club. He wrecked his car twice while driving drunk as well. Following completion of the program, he became active in AA, attending meetings and talking regularly with his sponsor. During his first year of recovery, he had a relapse that lasted about two months. After that, however, he was able to maintain abstinence for many years. His wife has been involved in Al-Anon and continues to attend meetings regularly. Twelve years agoabout a year after joining AADan was diagnosed with bipolar disorder. He was admitted to a psychiatric facility following a manic episode. Once stabilized, he was discharged and given a prescription for lithium. He regularly saw a psychiatrist, who monitored his response to the medication. Dan did very well and had no serious complications with his recovery until about two years ago, when he once again became manic. His mood became highly elevated. His need for sleep decreased from six hours per night to three. He usually was up before 5:00 A.M. and went out for breakfast before Linda was awake.

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Dan had always been a friendly and sociable man who enjoyed talking about work, sports, and politics. During his manic episodes, he became much more talkative and opinionated. He refused to listen to others during conversations. His discourses turned into long-winded monologues that bored other people. Dan also became argumentative with his wife and children, especially when they shared their concerns about the changes they saw in his moods and behaviors. During this phase, Dan worked long days, often not returning home until midnight. On weekends, he spent a great deal of time on the phone, discussing jobs or ordering building materials. He was quite busy, more so than he would have been normally. When he wasn't giving estimates or completing a home improvement job, he was fixing something at home, painting the house, or doing yard work. At first Dan refused all attempts by his wife and family to seek help for him. Linda became so upset with his refusal to get help that she temporarily left, taking their son with her, to live with their eldest daughter. This finally convinced Dan to seek a psychiatric reevaluation. It was discovered that he had stopped taking his lithium about three months earlier, something Linda had suspected. Dan was in an active manic state and had resumed drinking alcohol. Despite the fact that he was deteriorating, Dan refused all treatment recommendations. He told the evaluator that he didn't need help, and that not only did he feel fine, he was in control of his drinking and was even going to expand his business and make a lot more money. Over the next several weeks, Dan decompensated further. He become unable to manage his business. He quickly went through his savings and fell behind on his utility bills. Despite the fact that his phone and gas services were terminated, Dan continued living in his house alone. When Linda or his children visited, they often found no food in the house. Normally a good family man with no interest in other women, Dan started picking up women in bars and bringing them home. On one such occasion, his date stole all of his cash and fled the house while he was asleep. Dan's family was finally able to initiate an involuntary' commitment. He was kept in the hospital only a short time, however, because there was not enough concrete evidence that his life was in serious danger. Despite being manic, Dan refused the treating psychiatrist's attempt to restart lithium treatment for him. He left the hospital, refusing any follow-up care. He was very angry at his family for having him committed. For the next several months, he had only limited contact with them. Dan told

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Linda, his wife of twenty-five years, that he wanted a divorce. He changed the locks on the doors so she couldn't get in. His appearance deteriorated and he often was seen unkempt and unshaven. He also lost his dentures and never had them replaced. Any time he saw his wife or children, he picked fights with them. He accused Linda of ruining his life. Unable to work, Dan couldn't pay for his car insurance or for the upkeep of his car. He began borrowing money from neighbors or, if they refused, stealing from them. From time to time, he did odd jobs to pick up a few dollars. Dan often spent what little money he had on alcohol. He was kicked out of one of the local bars for picking a fight. Dan finally accepted treatment and was admitted to a dual disorder inpatient program. He was detoxified for alcohol, and his mood disorder was stabilized. Although he is doing much better now, the havoc caused by his relapse caused a tremendous burden for his family, and he is still separated from his wife. Assessment Criteria Bipolar Disorder, Manic The specific DSM-III-R* criteria for a current manic episode includes the following symptoms: 16 1. There is a distinct period of abnormally and persistently elevated, expansive, or irritable mood. 2. During the period of mood disturbance, at least three of the following symptoms have persisted (four, if the mood is only irritable) and have been present to a significant degree: ·

inflated self-esteem or grandiosity

·

decreased need for sleep (e.g., feels rested after only three hours of sleep)

·

more talkative than usual or feels a pressure to keep talking

·

flight of ideas, or the subjective experience that thoughts are racing

·

distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

·

increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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· excessive involvement in activities that have a high potential for painful consequences (e.g., buying sprees, sexual indiscretions, foolish business investments) 3. 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. 4. At no time during the disturbance have there been delusions or hallucinations for as long as two weeks in the absence of prominent mood symptoms. 5. The disturbance is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or a psychotic disorder not otherwise specified. 6. It cannot be established that an organic factor initiated and maintained the disturbance. Depressed and Mixed Subtypes The diagnosis of bipolar disorder, depressed, is made when an individual has the symptoms of a major depressive episode and has had one or more manic episodes as described earlier in this chapter. Features of a hypomanic episode are similar to those of a manic episode except that delusions are never present and other symptoms are less severe than those of a manic episode. The diagnosis of bipolar disorder, mixed, is made when the patient has symptoms of manic and depressed episodes intermixed or rapidly alternating every few days. 17 Assessment Issues Generally, in your role as counselor, you will not be called on to make initial assessments of individuals with the dual diagnosis of bipolar disorder and chemical dependency. These clients are usually seen initially in a mental health setting rather than in a chemical dependency treatment facility. The mental health counselor who evaluates such an individual should gather information about any alcohol and drug use, as such behavior often complicates recovery from bipolar illness and can be a factor in relapse. However, it is possible that family- or job-related problems, or difficulties associated with alcohol or other drugs, may bring such clients to a substance abuse clinic first. Therefore, you should be familiar with the symptoms and behaviors associated with this disorder.

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Suspect bipolar disorder in any client who presents with substance abuse, inappropriate elation, and grandiose mood. Ask about activity and energy level, patterns of sleep, buying sprees, and recent legal difficulties. Take note of the rate of speech and the way clients produce and express ideas. Those who speak rapidly and jump from topic to topic may be manifesting symptoms of mania. They may also display delusions or behave in a foolish or silly manner. If you obtain a family history of bipolar illness, the odds are great that such a client is also bipolar. If the client appears depressed, ask about a past history of manic symptoms. Often family members and friends can provide valuable information about past episodes that the client may be unable or unwilling to remember. Past medical charts are also helpful. As a rule, these clients will appear to function normally between episodes of illness. If you suspect your client has a bipolar disorder, a consultation and evaluation by a psychiatrist is in order. Since these clients display very poor judgment and insight regarding their behavior, a time delay might be costly to the individual and to society as a whole. In addition, evidence suggests that the sooner treatment begins for this disorder and the fewer episodes an individual has, the less severe the symptoms and the lower their degree of impact on social functioning. Counseling Issues Pharmacotherapy is the first line of treatment for bipolar disorder. The treatment of choice is lithium. Sometimes anticonvulsants such as carbamazepine (Tegretol) or valproic acid (Depakene) are used alone or in combination with lithium. Antidepressants are used to treat acute depressive episodes of bipolar illness; they may also be used to prevent future depressive episodes. Antipsychotics can help control severe psychotic or agitated states. Agitation and sleep disturbances are sometimes treated with benzodiazepines. The specific type or combination of medications depends on several factors: whether the client is experiencing an acute episode of illness, the specific clinical symptoms and behaviors, past and current responses to medications, and side effects. In recent years, the importance of psychotherapy has been emphasized as an important adjunct to pharmacotherapy for the treatment of bipolar disorders. Although no single approach to psychosocial treatments has been proved superior, individual, family, and group therapies can be helpful interventions. Educational interventions are needed to help clients and

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families understand these disorders, their treatment, common issues and concerns in recovery, and the potential benefit of self-help support groups. Little research or literature is available concerning psychosocial issues that affect individuals who have both chemical dependency and bipolar disorders. Any of the treatment issues for chemical dependency outlined in chapter 2 are relevant for the individual with bipolar illness. Following is a discussion of common issues, themes, or problems that can be addressed in counseling sessions. This discussion is based on our clinical experience and on Goodwin and Jamison's excellent review of issues in psychotherapy of bipolar clients. 18 Although discussed separately, many of these issues overlap. Medication-Related Issues A major therapeutic issue among bipolar clients is compliance with a medication regimen. Failure to take medication or stopping medication when symptoms seem well controlled usually leads to a recurrence of illness. People with bipolar disorders need to be maintained on lithium or other medications indefinitely (in most cases, for the rest of their lives). Without this prophylactic treatment, there is a great risk of relapse. A return of manic or depressive symptoms is often accompanied by a return to substance abuse, which, of course, greatly complicates recovery. You will, therefore, need to stress to your clients the importance of taking medications regularly and the need for regular blood tests to ensure a client is receiving the proper therapeutic dosage of lithium. Clients stop taking medications for many reasons, such as ·

unpleasant side effects

·

a belief that since symptoms have abated, the illness is cured

·

poor judgment associated with the breakthrough of symptoms

·

a sense of loss concerning the energy, productivity, or creativity experienced during manic or hypomanic periods

· pressure from members of self-help groups to stop taking medicine out of the belief that people who take medicine aren't really clean or sober Besides stressing compliance, discuss with clients the differences between taking a medication for bipolar disease and taking alcohol or other drugs to get high. Some clients will also benefit from behavioral rehearsals in which they practice responding to well-meaning people who urge them to stop taking medications. Goodwin and Jamison identified a number of risk factors for lithium

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noncompliance based on studies of clients with bipolar and unipolar disorders. These factors include being in the first year of lithium treatment; having a history of noncompliance; being younger and male; having experienced fewer episodes; having a history of grandiose or euphoric manias; experiencing an elevated mood; and complaining of ''missing highs." 19 The side effects associated with lithium can be unpleasant; they include excessive urination, hand tremors, nausea or vomiting, fatigue, lethargy or drowsiness, or dulling of senses.20 Counselors should routinely ask clients about side effects. Report significant side effects or changes in side effects to the prescribing physician. You can increase compliance by asking clients and their families if the medication is being taken regularly and if side effects are being experienced. Ask, too, about symptoms of bipolar illness to determine if the client is experiencing any significant changes in moods, thought processes, behaviors, or health habits (eating, sleeping, etc.). If a change in regimen is indicated, the psychiatric consultant should consider adjusting the dose or adding additional medications. Some clients may report they are taking medications when they are not actually doing so. Stay in close touch with the treating doctor to keep up-to-date on results of blood tests that monitor therapeutic drug levels. Since medication is considered the most important intervention with bipolar clients, some clients do not see any need to address problems caused by the illness or to make any personal or lifestyle changes. While supporting the role of medication in recovery, you can encourage clients to discuss psychosocial problems caused by the illness, adjustments to treatment, and problems or stresses that may contribute to an eventual manic or depression relapse. Supportive or problem-solving therapies can benefit such clients. Alcohol and Drug Use As a matter of routine, ask bipolar clients whether they experience any cravings for alcohol or drugs. Asking such questions can head off potential relapses and reinforce the need for continuous monitoring of cravings, particularly in the early weeks and months of abstinence. Teach clients behavioral and cognitive strategies to cope with their cravings.21 Current substance use can interfere with the effectiveness of medication, reduce motivation to recover or to attend treatment sessions or support group meetings, impair judgment, increase the relapse risk for bipolar illness, and induce other mood changes. Even small amounts of alcohol

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can affect sleep patterns, which in turn can exacerbate or precipitate a manic state. 22 Therefore, be sure to ask clients about current use of alcohol or other drugs. Denial of Bipolar Illness Many individuals with bipolar mood disorder deny that they have a psychiatric illness and lack insight into the severity of their illness. This accounts for the fact that many enter treatment as a result of pressure from families or friends, or because they have been committed following a severe eruption of symptoms in which their behavior threatens their own or another's well-being. Denial also spurs some clients to stop treatment once symptoms remit. They believe they no longer have the illness and are exempt from future episodes because they currently are asymptomatic. On the other hand, the client may deny the chemical dependency or attribute the abuse of alcohol or other drugs solely to the psychiatric illness. In either case, you will need to address denial by discussing the specific symptoms and effects of both disorders on the client's life and the effects on the family. Educate the client and family on the nature of bipolar illness and emphasize the need for ongoing treatment and the possibility of relapse. Grief Associated with Losses From the client's perspective, treatment and recovery bring about many major adjustments and losses. These include, but are not limited to, loss of the following: relationships, ease in social interactions, jobs or career, financial resources, potential for achievement, and self-esteem. Regardless of the actual negative consequences of bipolar illness, clients often believe that a euphoric mood and high energy are good qualities that make positive contributions to their lives. Some, for example, state frankly that they ''miss the manic high" and don't enjoy the stability of moods brought about by treatment. When clients in treatment compare their present mood to how they functioned when manic, they often complain that they feel less lively, productive, ambitious, intense, interesting, joyful, funny, creative, or sexual. Some clients even feel a "loss of time" because they sleep more when not manic and have less time to accomplish things. On top of these losses, clients are also asked to stop drinking alcohol or taking drugs. All of these losses contribute to a grief reaction that you should be prepared to address in sessions. Clients with a bipolar disorder often are unable to experience (or

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express) sadness or disappointment. Evaluate clients to determine whether they need help in coping with this issue, particularly as it is related to the loss of significant relationships, roles, or activities. Family and Interpersonal Relationship Issues Bipolar disorders can create emotional and financial havoc for the family. This is especially true when the illness is complicated by chemical dependency, suicidality, or bizarre behaviors. Help clients by discussing the impact of these disorders on the family. Doing so can reduce clients' feelings of guilt and shame. In addition, work with clients to determine when and how to make amends, and discuss how to involve the family in treatment sessions or self-help recovery programs (e.g., Al-Anon, Nar-Anon, and programs for families of the mentally ill). When family members are involved in treatment and recovery activities, they are in a better position to support a client's recovery as well as deal with their own feelings, reactions, experiences, and fears. Involvement also gives the family a way to learn about these complex disorders and to get support and advice from professionals and other families. Families can learn how to recognize the early signs of relapse and learn what to do to ensure that the client gets help before a full-blown manic relapse or a chemical dependency relapse occurs. Since affective disorders can run in families, some clients with bipolar illness may express concerns about passing the illness on to their children. This is a realistic concern that you should discuss openly in your sessions. If the client has children, ask how they are functioning. If you suspect the children are afflicted by some type of mental illness, refer them for evaluation. Some clients are unsure of what, if anything, they should tell their lovers, friends, co-workers, bosses, or neighbors about their bipolar illness. Clients who are dating may express concerns about the impact of lithium or other medications on their capacity to be fun and interesting to others. Some individuals who felt more at ease socially during their hypomanic or manic phases, or because of the effects of alcohol or other drugs, may need practical help on issues such as starting conversations, asking for dates, or facing and resolving interpersonal conflict. Each situation may require a different clinical response. Work with clients on a case-by-case basis to explore and discuss family and interpersonal concerns to determine the best way to handle them. Interpersonal psychotherapy, a form of treatment developed initially for

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depressive illness, is proving effective with bipolar clients. This therapy focuses on four major areas of intervention: coping with grief, interpersonal conflicts, role transitions, and interpersonal deficits. 23 In addition, cognitive-behavioral interventions can help clients identify and cope with negative thoughts, such as resistance to taking medications for their illness.24 Other Psychological Effects of Bipolar Illness Bipolar disorders can be devastating. Clients frequently report that they feel stigmatized, defective, and shameful for having this disorder. Psychological scars often result. Clients need help discussing these issues and what the issues mean to them. While treatment offers many benefits, it also causes many adjustments for the client. As mentioned earlier, clients often perceive treatment and recovery as producing losses and significant changes in functioning. Understandably, they see some of these changesespecially a decrease in creativity, energy, or productivityas negative. The loss of these may contribute to feelings of lower self-esteem and worries about personal competence. Bipolar illness can also have a significant impact on vocational and academic functioning. For some clients, the course of illness causes major changes in functioning, even if clients are treated for their illnesses and their manic or depressed moods are stabilized. Expectations and Course of Recovery Treatment helps the majority of individuals with bipolar illnesses, but it is not equally effective in all cases. The course of recovery may be uneven: some symptoms may improve rapidly, while others may take longer to improve, or symptoms may return or worsen after an initial period of improvement. As a result of an uneven course of recovery, clients may feel frustrated. They often blame their doctors or counselors since the clients naturally expect positive results from treatment. Some dual diagnosis clients become frustrated because while they do well recovering from one disorder, they may have a harder time struggling with the other illness. A client may, for example, abstain from alcohol and drugs only to find that mood symptoms still fluctuate over time, causing much confusion and concern. Discuss with clients their understanding of their illness, treatment, and the possible courses of recovery. Explore their specific expectations of treatment, pointing out that treatment effects vary among clients. This can

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help them change expectations and become more realistic about the potential ups and downs of recovery. Relapse All clients need to be educated about the possibility of relapse of bipolar illness. Teach clients how to recognize the early warning signs of manic or depression relapse and what steps to take to avert a full-blown episode. Clients often worry about an impending relapse when they begin to feel good or when they feel ordinary levels of sadness. They may have trouble discriminating between "normal" moods and moods that are symptoms of an affective disorder. Although stressful life events can contribute to a bipolar relapse, it isn't unusual for an individual with a history of multiple episodes of mania to relapse in the absence of specific external stresses. Complex biological factors may increase the client's vulnerability to relapse and may trigger it. Encourage clients, especially those with a history of recurrent bipolar episodes, to discuss their fears concerning another episode. In chapter 11, we'll present specific guidelines for dealing with relapse of both chemical dependency and psychiatric illness. Suicidality/Psychiatric Hospitalization Remember to ask each client about suicidality, particularly during acute phases of manic or depressed episodes. Psychiatric hospitalization is indicated if the client has a suicide plan, attempts suicide, or presents a significant suicide risk based on past history and current behavior. Even in the absence of suicidality, hospitalization may be needed to stabilize an individual experiencing a manic, depressed, or mixed episode that seriously impairs judgment or functioning. Counsel families on strategies for initiating psychiatric hospitalization in cases in which the client lacks insight into the severity of his or her symptoms. Some cases require an involuntary commitment because the client refuses all attempts to help. You may be called on to help the family overcome their own reluctance; family members who feel guilty of being disloyal or who fear repercussions may hesitate to initiate a commitment, even when the loved one's life is in jeopardy. Structure and Routine Nonstressful life events can disrupt the structure, routine, or rhythm of daily life and can play a role in relapse of bipolar illness. Examples of such

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disruptive events include trips or vacations, jet lag, or alterations in work schedule (overtime, shift work, and so on). Some experts believe that clients should maintain a careful routine in which they eat meals, go to sleep, and wake up at a similar time each day. Work with clients to develop their structure and routine. Advise them to monitor their daily activities closely in order to be aware of changes in routine that might threaten their emotional equilibrium. Clients also benefit from decreasing the amount of stimulation in their lives. Involvement in too many activities or projects can create stress. One practical intervention is to help these clients evaluate the number and types of their activities and determine if and how they should cut back. Monitoring Moods and Episodes of Depression Clients sometimes fear that a normal depressive reaction will lead to an episode of major depression or that a state of well-being will escalate into hypomania or mania. 25The truth is that while periods of sadness or lethargy are sometimes a normal part of living, they can also be symptoms of a clinical depression. Similarly, feeling good, energetic, or productive can be normal, or it may be a feature of hypomania.26 You can help your clients discriminate normal moods from those that may be part of an affective syndrome. One way is to ask clients to keep a daily journal or log in which they rate moods. Doing so allows them to see the severity, effects, and patterns of their moods as well as their response to treatment over time. Additionally, a journal reinforces the importance of the client's regularly monitoring his or her symptoms, thus making the client a collaborative partner in the treatment effort.27 Need for Ongoing Support and Lifelong Treatment Clients often need lifelong support and involvement in professional treatment for bipolar illness and chemical dependency. Such support may come from professional caregivers, members of AA or NA, or members of mental health support groups. Clients sometimes struggle with the idea that they have a chronic illness; they resist the need for long-term care, particularly during those times when the symptoms of their mood disorder have abated. Counsel clients that ongoing treatment is preventive and that it can reduce the chances of a subsequent relapse to mania or depression. Usually the number of sessions with treating professionals can be reduced as clients improve. Similarly, some clients also cut back on their participation in self-help programs. Stress to your clients that they should

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discuss with you or another professional any desire to reduce involvement in treatment. Encourage them to call you or a doctor should significant changes in symptoms occur between sessions. This intervention-the proverbial stitch in time-may be enough to avert a potentially serious relapse. The Continuum of Care Detoxification Clients with bipolar symptoms can be detoxified in a chemical dependency facility or psychiatric hospital. They are often admitted with some combination involving symptoms of alcohol or drug intoxication, mania, and depression. If mania or severe depressive symptoms are present, detoxification in a psychiatric hospital is indicated; in our opinion, outpatient detoxification for these clients would be inappropriate. Chemical Dependency Rehabilitation Programs/Halfway Houses Clients in rehabilitation programs tend to do too much too soon, particularly if they still manifest symptoms of mania or hypomania. For example, they may read all of the AA Big Book or the NA Basic Text, then superficially run through the entire Twelve Steps during their first several days in the program. Some of these clients tend to dominate treatment groups, making themselves the center of attention. They may talk loudly and excessively, saying little of relevance to anyone but themselves. Occasionally their behavior is so inappropriate that they become a source of amusement for other group members and thereby a major distraction to the treatment milieu as a whole. Chemical dependency rehabilitation should be deferred until these manic symptoms are absent or are well controlled. We make this suggestion despite the fact that manic clients can be enjoyable, pleasant, motivated (sometimes to excess), and often fun to talk to. For the sake of the milieu, however, it is best to wait until the client's mood disorder is stable before beginning rehabilitation treatment for substance abuse. These clients can also benefit from halfway house programs once their psychiatric illnesses are stabilized. Clients who need a longer-term, supportive recovery environment because of vocational deficits or poor family or social support systems can be considered candidates for halfway house programs. In such cases, the staff at the halfway house should keep close contact with the mental health professional providing treatment for the bipolar illness.

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Psychiatric Hospitals Individuals with bipolar illness sometimes require psychiatric hospitalization when their behavior represents a risk to their own well-being or that of others, or when it seriously impairs social, family, or occupational functioning. As we mentioned before, it is not unusual for clients to deny or minimize the severity of the affective diagnosis and end up in the hospital as a result of an involuntary commitment. Pharmacotherapy, psychosocial treatments, and self-help programs are commonly used during the inpatient phase of treatment. All clients treated in an inpatient setting will need follow-up treatment for their dual disorders. If the client relapses to alcohol and drug use and such use was a factor in psychiatric hospitalization, this issue needs to be addressed during the inpatient phase of treatment. Such clients need to continue focusing on alcohol and drug problems as outpatients. They should also be referred to AA or NA or both, depending on the specific nature of the chemical dependency. Partial Hospital and Day Treatment Programs Clients with persistent symptoms and severe psychosocial impairments caused by bipolar disorder and chemical dependency can benefit from partial hospital programs or day treatment programs. Such programs offer structure and support, as well as an opportunity to address pertinent issues outlined in the earlier section on counseling issues. Outpatient Treatment Many clients with bipolar illness and chemical dependency can be successfully treated as outpatients, and any of the counseling issues outlined earlier can be addressed in outpatient treatment. If a client is receiving treatment in a chemical dependency outpatient clinic, and a bipolar affective disorder is subsequently diagnosed, treatment can continue in the substance abuse facility. In such cases, make sure that psychiatric consultation is available, that counselors are familiar with treatment issues for bipolar disorder, and that they balance their approach to the dual disorders. Under no circumstances should counselors attempt to provide treatment for the bipolar disorder if they have not received proper training and supervision. If the client is treated at a mental health clinic, counselors should address issues pertinent to alcohol or drug use. The counselor can routinely inquire about use of substances, cravings or desires to use, and activities

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related to AA or NA involvement. Otherwise, the client may focus solely on the mood disorder and minimize or deny the addiction. Pharmacotherapy Lithium carbonate, an orally administered salt, has been the mainstay of treatment for bipolar disorders, both for acute mania and for long-term prophylaxis of recurrent mania or depression. A review of more than a hundred studies involving three thousand patients in twenty different countries indicates that lithium is effective in about 60 percent of such cases. 28 When indicated, antidepressant, antianxiety, or antipsychotic medications can be added to the lithium regimen. Research suggests that generally, clients who do not respond to or comply with a lithium regimen are rapid-cyclers or have organic affective disorders. These individuals may benefit from anticonvulsant medications such as carbamazepine or valproic acid. Studies show that results with these medications are comparable to those of lithium and antipsychotic medications.29 Self-Help Programs Once the affective disorder symptoms have been resolved or markedly improved, these clients may do well in a Twelve Step program. They are frequently very helpful in setting up meetings and events. Sponsorship by an appropriately chosen sponsor can be extremely helpful. A good sponsor for these clients would be someone who appreciates the need for ongoing preventive medication and would therefore encourage rather than discourage compliance. Also, the sponsor can help monitor the mood of the client and can recommend mental health evaluation if symptoms worsen or reemerge following a period of remission. Depression and manic-depression support groups are also helpful to these clients. Such programs provide them with an opportunity to learn more about the illness and recovery and to gain support from others with whom they can easily identify. Summary Bipolar disorder is a severe and chronic type of mental illness that is closely associated with chemical dependency. This combination of disorders can wreak havoc on clients and their families. People with this combination of conditions often require lifelong treatment

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to keep their mood swings under control. Although they may receive treatment in either a chemical dependency or a mental health setting, they are more likely to be seen in the latter. Treatment is effective for most clients with bipolar disorder, but continued abuse of alcohol or drugs can complicate recovery and increase the risk of psychiatric relapse. Therefore, clinicians should routinely inquire about any use of substances. Although psychosocial treatments and self-help programs can help, anti-manic medications such as lithium and anticonvulsant medications such as carbamazepine are usually needed to control symptoms. In some instances, antidepressants are indicated as adjunctive therapy. Since relapse to the manic phase is common (and can be life-threatening), clinicians need to be prepared to help families initiate involuntary psychiatric hospitalization. Ongoing participation in AA, NA, CA, or other mental health support groups is very useful for dual-disordered clients who experience bipolar illness.

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Chapter 8 Anxiety Disorders and Chemical Dependency An Overview Anxiety disorders are best understood as a disturbance in the way the body responds to the threat of dangera disturbance, that is, in the ''fight or flight" response. Normally, when a person is confronted with a stressful or dangerous situation, the brain evaluates the situation and sends a hormonal signal to the adrenal glands, causing them to secrete stress hormones. The heart responds by beating faster and harder to pump more blood to the muscles; the breathing rate increases to provide more oxygen to the body. The sweat glands are also stimulated to cool the body down. More blood is shunted to the muscles, and they become tense as they prepare to flee the danger or fight it. At the same time, the brain causes the person to experience fear. Anxiety and phobic disorders occur when this adaptive response is triggered inappropriately, when it persists well beyond its usefulness, or when a person restricts activity in order to avoid having such a response. These disorders are among the most frequent psychiatric problems in the adult population. In the United States, phobic disorders have a lifetime prevalence rate of about 14 percent. 1 Because of the cultural assumption that alcohol produces relaxation, there has historically been an association between anxiety disorders and alcoholism. This centuries-old belief dates back at least as far as the time of Hippocrates, who suggested in his Aphorisms that "wine drunk with equal quantities of water puts away anxiety and terrors." In the mid-1950s, Conger stated the "tension reduction" hypothesis of alcoholism, which postulated that people drink alcohol in order to reduce tension and anxiety and that continued drinking is an attempt to avoid experiencing these

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emotions. 2 Although later studies have shown that alcohol in some situations may increase tension rather than decrease it,3 people with anxiety disorders frequently resort to drinking alcohol or using other drugs in their belief that it will help them cope with their anxiety problems. This form of self-medication is common among dual diagnosis patients. Given these facts, it is not surprising that research has shown that for many alcoholics and other substance abusers, anxiety disorders precede chemical dependency.4 However, it is equally important to note that chronic alcohol and drug abuse may worsen anxiety symptoms and turn them into more severe and debilitating conditions.5 Whether or not anxiety disorders are a cause of chemical dependency or an effect, it is clear that within the families of individuals with anxiety disorders, there is a significantly greater rate of alcohol and drug dependence than among families without these psychiatric illnesses.6 As described in the DSM-III-R, anxiety disorders include panic disorder, phobic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and generalized anxiety disorder. Phobias are the most common anxiety problem in the general population, while panic disorder is most common among clients seeking treatment. Interestingly, these conditions typically cluster within families. As a result parents, children, and siblings of clients with anxiety problems have a higher prevalence of these conditions than do members of the population at large. This suggests that heredity may be an important factor in the susceptibility to anxiety disorders. Panic Disorder Panic attacks are discrete periods of intense fear or discomfort lasting from a few minutes to several hours. In the early course of the illness, these attacks are almost never anticipated, nor are they caused by exposure to specific situations. After the illness has progressed, however, the panic is frequently associated with specific situations such as driving on a bridge or being in a crowded shopping mall. Even so, being in those situations does not always provoke a panic attack (although the person may be deeply concerned that an attack will, in fact, occur). Because of this fear, people with panic disorder who seek treatment will frequently have several symptoms of agoraphobia. Agoraphobia (meaning ''fear of the marketplace") is the intense fear of being in places or situations where escape is either difficult or humiliating.

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People with agoraphobia fear travel and often need someone to accompany them when away from home, in a crowded location, or when traveling on a bus, train, or car. They avoid crowds, especially crowded stores, theaters, or offices. These individuals frequently stay home and will only go into public with a family member or trusted friend. Because this disorder is more commonly diagnosed in women, it has acquired the nickname "housebound housewife syndrome." One psychological symptom of panic is the abrupt onset of intense fear of dying, going crazy, or acting out of control. Physical symptoms include shortness of breath or the feeling that one can't catch one's breath, dizziness, palpitations of the heart, shaking or trembling, sweating, nausea, tingling or numbness, hot or cold flashes, and chest pain. Panic disorder typically begins before age thirty. Panic disorder with agoraphobia is about twice as common among women than men. However, for panic disorder without agoraphobia, men and women are equally affected. Both panic disorder and agoraphobia are frequently associated with alcohol and drug abuse. Panic disorder is 2.6 times more common among alcoholics than nonalcoholics. Studies have found that between 10 percent and 20 percent of agoraphobics meet either the Michigan Alcohol Screening Test (MAST) or for alcoholism. DSM-III criteria7 Other reports show that 28 percent of hospitalized alcoholic women have at one time suffered from agoraphobia, thereby making this condition the second most common dual diagnosis among alcoholic women.8 Furthermore, about 4 percent of drug abusers have panic disorder, the rate again being nearly twice as high among female drug abusers as among male drug abusers.9 Although a substantial number of agoraphobic clients appear to meet diagnostic criteria for alcoholism, a far lower number of clients with "pure" panic disorder have alcohol problems. In one study, only 8 percent of panic-disordered individuals scored in the alcoholic range on the MAST, while 27 percent of agoraphobics with panic attacks scored as alcoholics.10 Furthermore, in a study by one of the coauthors of this book (Moss), a positive family history of alcoholism was found in 27 percent of agoraphobics and 20 percent of social phobics, suggesting there may be an inherited link between these anxiety disorders and alcoholism.11 Abuse of alcohol and drugs can confuse the diagnostic picture of panic disorder. For example, withdrawal from alcohol, tranquilizers, and barbiturates may produce symptoms similar to those seen in panic. In addition,

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intoxication with amphetamine, cocaine, and even caffeine may induce panic-like symptoms. Note that clients whose panic symptoms are directly produced by intoxication or withdrawal from drugs do not typically have panic disorder; instead, they are diagnosed as having an organic anxiety syndrome. The difference is that with abstinence and sobriety, panic abates in patients with organic anxiety but not in patients with true panic disorder. However, chemical dependency does complicate their condition; smoking marijuana or using stimulants or hallucinogens, for example, may precipitate a full-blown panic attack in someone with panic disorder. Case History: Elaine Elaine is thirty-six years old, married, and a college graduate with two children. She used to work as a computer programmer, but after she married Steve and became pregnant with their first child, she decided to give up her career and stay home to raise her family. A few months after the baby's birth, she experienced an unusual event. She had just put the baby to sleep after an afternoon feeding and was sitting alone in the living room watching television when "it" happened. Suddenly, she felt very peculiar. Her heart sped up and began to pound. She noticed her breathing got faster, and she felt as if she couldn't catch her breath. Her thoughts began to race. She felt dizzy. She thought to herself, My God, what's happening to me? Am I having a heart attack? I'm all alone here with the baby. Who will take care of him? And then the fear began. It started as a tiny doubt and grew into absolute terror. This event lasted for about fifteen minutes, and then it slowly started to abate. When it ended, Elaine went to the bar in the den and poured herself a stiff drink. She was relieved the terror was over, but she was still very afraid. She also decided not to tell her husband about it, because she felt he would think her a hypochondriac. A few months later, Elaine went shopping at a mall with her baby. After leaving a shoe store, she noticed her heart beginning to pound. She sat down, but it didn't help. She had another attack like the one a few months before, but this time she was away from home. Terror struck. Clutching the baby, she ran through the mall to the parking lot. She kept thinking, I hope people don't see me like this. I 'd better get home! Elaine made it to the house, and by the time she arrived, the attack was over. She was relieved and felt comforted that she was in a safe and familiar place. After she put the baby down, she walked into the den and poured herself a drink to relax. These events repeated themselves three or four times. Although Elaine

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occasionally had attacks at home, the episodes away from the house were more terrifying. She started using the baby as an excuse for not going out. She felt much more secure and safe at home. Whenever she felt a little nervous at home, she was afraid an attack would strike, and so she would pour herself a drink to calm down. She eventually drank daily, consuming from five to six drinks at each sitting. Over time, she developed considerable tolerance for alcohol. Often, however, she injured herself by falling accidentally or burning herself in the kitchen. The quality of mothering she provided to her infant declined. Not surprisingly, her daily drinking became a major source of problems between her husband and her. Elaine eventually reached the point where she rarely went beyond the front door of the house without her husband as an escort. She also developed a real dependence on alcohol, increasing her consumption to about a dozen drinks a day. She still had attacks, though, and went to many physicians seeking help. An alert internist eventually referred her for psychiatric evaluation. The psychiatrist diagnosed both conditions: panic disorder with agoraphobia, and alcohol dependence. She was treated with an anti-panic medication and behavior therapy, which helped her gradually venture away from the safety of her home. Within six weeks, her panic attacks completely stopped. She was able to leave the house regularly to attend outpatient treatment for her alcohol addiction. At first she would only come to treatment if her husband drove her; gradually, though, she was able to make it by herself. Assessment Criteria DSM-III-R* defines panic disorder as a disorder in which an individual has one or more discrete panic attacks. Such attacks arise unexpectedly, that is, without exposure to a situation that always causes anxiety. Also, the attacks are not triggered by situations in which the person is the focus of attention. Either four of these attacks occur during a four-week period, or one or more attacks are followed by a period of at least a month in which the person fears having another attack. At least four of the following symptoms develop during the attack: shortness of breath or smothering sensations, dizziness or faintness, palpitations of the heart, trembling or shaking, sweating, choking, nausea, feelings of unreality, numbness or tingling, flushes or chills, chest pains, fear of dying, or fear of going crazy or *Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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being out of control. During some of these attacks, at least four of the above symptoms develop suddenly and increase in intensity within the first ten minutes of the attack. 12 DSM-III-R defines panic disorder with agoraphobia as a disorder in which the individual meets the above criteria for panic disorder and has symptoms of agoraphobia (the marked fear of being in places or situations from which escape might be difficult or embarrassing or in which help might not be available). As a result of this fear, the person either restricts travel or needs a companion when away from home. 13 Assessment Issues The assessment of panic disorder clients is relatively straightforward: ask clients about the occurrence of panic attacks. Because the term may have a different meaning for different people, ask specifically about episodes that strike "out of the blue" and that consist of heart palpitations, sweating, rapid breathing, and an intense feeling of fear. Along with these inquiries about feelings, ask clients whether they have had thoughts of going crazy, dying, or making a public spectacle of themselves. Since panic attacks often abate as suddenly as they begin, find out how episodes ended. Medical conditions such as low blood sugar, an overly active thyroid gland, heart problems, or certain adrenal tumors can mimic panic attacks; therefore, medical consultation is of great importance in assessing these clients. Similarly, intoxication with cocaine, amphetamine, and caffeine, or symptoms of withdrawal from alcohol, minor tranquilizers, or barbiturates, may appear indistinguishable from the symptoms of true panic attacks. A toxic screen for drugs will distinguish stimulant use or depressant withdrawal from panic disorder. Ask clients if they avoid situations or places that they think may pose problems for them. Specifically inquire about avoidance and fear of being away from home or in crowded public places; driving in tunnels, on bridges, and on freeways; signing one's name in public; and excessive fear of public speaking, flying, and riding in elevators. Determine if this pattern of avoidance has any negative impact on the quality of the client's life. The next question to ask is, How do you cope with your fear? This is the time to ask about the use of alcohol or other drugs as a means of dealing with these situations. Panic disorder significantly increases a person's risk for suicide.14 Given the fact that substance abusers, in general, are also at heightened risk

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for suicide, it is vital for clinicians to assess chemically dependent, panic-disordered individuals for the presence of current suicidal thoughts, their past history of suicide attempts, the seriousness of intention during the previous attempts, and the availability of guns, knives, or stockpiled medications. Again we must emphasize the importance of obtaining good psychiatric consultation when assessing clients whom you suspect of having a psychiatric disorder. Counseling Issues A number of psychological, cognitive, interpersonal, and lifestyle interventions can help clients reduce the severity and frequency of panic attacks, relieve other anxiety-related symptoms, and improve overall health. These interventions include, but are not limited to, breathing and relaxation techniques, meditating, regular exercise, dietary modification, assertiveness training, communication skills training, exposure strategies (confronting the feared object or situation), anxiety management, changing anxious or worrisome thoughts or beliefs, or participating in support groups. Several excellent books are available that discuss these interventions in greater detail. 15 As a counselor, you can help clients in several ways: · Conduct counseling sessions that focus on understanding and coping with specific problems or issues that contribute to panic or anxiety syndromes. · Directly teach the client to use one or more techniques for coping with symptoms of panic or anxiety. (Many self-help books and audiotapes can help in this process.) ·

Refer the client to other professional treatment or self-help programs that teach these methods.

·

Monitor the client's ongoing use of other strategies.

·

Explore the client's resistances or other roadblocks to treatment.

As is true with other psychiatric disorders, the recovery process is facilitated by educating the client and family about dual disorders and the recovery process. Use homework assignments to encourage clients to work actively on making specific intrapersonal or interpersonal changes. For example, instruct clients in the use of symptom rating sheets or of journals or logs that monitor thoughts or feelings. Conduct behavioral rehearsals to prepare clients for

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the types of anxiety-provoking situations they are likely to encounter. Proper Breathing Improper breathing exacerbates symptoms of anxiety and panic. Teaching clients to slow and calm their breathing will help reduce these symptoms. Proper breathing will allow them to feel more relaxed and in control of themselves and their feelings. Encourage clients to practice these techniques each day. 16 Relaxation Relaxation strategies can work to reduce symptoms of anxiety and panic. Progressive muscle relaxation techniques, developed by Dr. Edmund Jacobson, are commonly used to increase relaxation and reduce anticipatory anxiety. With this approach, clients lie on the floor and are coached in releasing tension from different parts of the body. Imagery and visualization are also helpful. The counselor asks clients to imagine themselves in a peaceful place and to return to this place each time relaxation techniques are practiced. Meditation, of which there are many varieties, is also valuable. If you don't teach meditation, refer clients to a meditation class in your area. Relaxation and stress-reduction methods can usually be practiced by clients for a half-hour or more per day. The regular use of any of these helps prevent stress from accumulating, increases energy and productivity, improves concentration and memory, reduces insomnia and fatigue, prevents or reduces psychosomatic disorders, and increases self-confidence.17 Exercise and Diet Encourage clients to practice a regular program of exercise to reduce tension and frustrations and to improve both physical and psychological functioning. Stimulant drugs, including caffeine (found in coffee, tea, colas or other soft drinks, and other products) and nicotine (found in cigarettes), may contribute to anxiety symptoms. Eliminating these compounds from the diet is a wise idea. Improving diet, nutritional intake, and eating habits can also reduce panic and anxiety as well as improve overall health and fitness. Help clients evaluate their diet and their eating and smoking habits to determine if there is any connection between these and their symptoms of panic or anxiety. In some instances, you may wish to refer the client to a nutritionist or a physician for help with dietary issues.

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Interpersonal Issues Some experts feel that issues involving relationships with other people may play a role in triggering panic and other anxiety symptoms. Such issues include suppressed feelings; difficulty communicating with others; an inability to express thoughts, feelings, or opinions assertively; or an inability to negotiate or resolve conflicts. Improving assertiveness and communication skills may help clients decrease panic or anxiety and feel better about themselves overall. 18 Support Groups Participating in self-help groups is also very beneficial for clients with panic and other anxiety symptoms. For agoraphobic individuals with panic attacks, the TERRAP (a contraction for "territorial apprehensiveness") program may be a very useful adjunct to professional treatment. However, some clients with severe panic, anxiety, or phobic symptoms may be unable to participate in such programs until their symptoms are under control. Changing Thoughts and Beliefs Many of the cognitive techniques discussed in chapter 6 also apply to helping clients with symptoms of panic and other anxiety disorders. Interventions include identifying and overcoming negative self-talk, challenging mistaken beliefs or distortions, and increasing positive selfstatements. Many excellent books are available that outline cognitive interventions. 19 Medications Pharmacologic treatment may be useful for some clients who have panic and other anxiety disorders. Three classes of medications have been shown to be effective in treating panic symptoms: ·

tricyclic antidepressants such as imipramine (Tofranil and others) and desipramine (Norpramin and others)

·

monoamine oxidase inhibitors (MAOIs) such as phenelzine (Nardil) and tranylcypromine (Parnate), which are also used to treat depression

·

benzodiazepines such as alprazolam (Xanax) and diazepam (Valium)

Use of these medications must be tailored to the needs of the individual clients, and, as with any medicines, there is the risk of side effects. The tricyclic antidepressants, for example, may produce dry mouth, constipation,

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dizziness, or sexual problems. Treatment with MAOIs requires that patients strictly maintain a special diet. Benzodiazepines have a high potential for abuse; their use in chemically dependent clients poses a risk of developing a new addiction and is usually contraindicated. As in other dual diagnoses, your clients may need help exploring thoughts, beliefs, and feelings regarding the use of medications. Emphasize the need for this approach and point out that using medicines does not mean they are not "sober" or "clean." Instruct clients to be discreet about telling others they are using prescription drugs, since well-meaning people in self-help groups may make them feel guilty or pressure them to stop. Phobic Disorders Thephobic disorders are marked by irrational avoidance of a specific dreaded object or situation that provokes anxiety. This avoidance can be a source of personal distress, or it can result in significant interference in social functioning. In DSM-III-R, phobic disorders are subdivided into two main diagnostic categories: social phobias and simple phobias. Social phobias are those in which the person has a persistent fear of one or more situations where evaluation or scrutiny by others may occur. The person has a fear of doing something that will be humiliating or embarrassing. Examples include fear of public speaking (relatively common), using public lavatories, eating in the presence of others, or writing in the presence of others (for example, signing one's name to a check). Exposure to the feared situation almost always provokes an immediate anxiety response. Predictably, afflicted people avoid these social situations to the point where doing so interferes with their work, social activities, or relationships. 20 Simple phobias are persistent and irrational fears of specific objects or situations. Examples include fear of dogs, snakes, insects, or mice. Although many people have irrational fears of such things as spiders, these fears have little impact on their lives and rarely compel them to seek treatment. However, simple phobias such as fear of air travel, heights (acrophobia), confined spaces (claustrophobia), and blood or tissue injury are more likely to impair a person's ability to function and thus are more likely to motivate him or her to ask for help.21 Studies suggest that anywhere from 18 percent to 33 percent of alcoholics have a severe form of phobic disorder.22 Up to 23 percent of drug abusers have a phobic problem, and anywhere from 20 percent to 35

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percent of social phobics have alcohol abuse problems. 23 However, it is not clear whether phobic problems are the cause of substance abuse or a consequence. Evidence supports the notion that having an anxiety disorder such as a social phobia doubles the risk for the later development of a substance abuse disorder,24 which is hardly surprising, since the majority of phobic individuals use alcohol to reduce their anxiety. On the other hand, a study conducted in England demonstrated that among alcoholics, abstinence significantly improved phobic symptoms.25 Thus, the two conditions seem intertwined to a significant degree. Counseling Issues The initial difficulty a counselor may experience in working with phobic clients is simply getting them to come in for treatment. By definition, agoraphobia frequently prevents patients from coming to residential treatment facilities. These clients do especially poorly in locked-ward settings. Freeway, bridge, elevator, or tunnel phobias may preclude travel to a clinic or rehabilitation program. Social phobics may experience extreme anxiety and refuse participation when confronted with the proposition of working in therapy groups under the scrutiny of others. Like agoraphobics, they respond poorly to residential settings in which there is intense social interaction. As a chemical dependency counselor, you must be aware that such avoidance is not the same as the resistance seen so often in chemically dependent clients. Confrontational techniques or interventions are more likely to reduce cooperation than enhance it. One effective strategy for phobic complaints is systematic desensitization. In this approach, clients are gradually exposed to the feared object or situation, either in reality or imagination, so they get used to it slowly and non-threateningly. The same strategy works in bringing phobic clients into treatment for substance abuse. Encourage clients with freeway, bridge, tunnel, or elevator phobias to have another person drive them to the clinic for outpatient visits. After comfortably and safely traveling over the same route repeatedly, the client will gradually be desensitized to the bridge, for example, that must be passed over to get to the clinic. Agoraphobic clients are best treated initially in an outpatient context; they can be encouraged to eventually come to treatment in the company of someone with whom they feel safe. As they become more comfortable with the treatment setting, they may feel confident about coming on their own. However, it is important that agoraphobic clients with panic attacks

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be treated by a psychiatrist with medications for the panic symptoms prior to entry into treatment for chemical dependency. If such clients experience a panic attack at the clinic, they may become fearful of the setting and may never return. Clients with social phobias are best treated initially in individual therapy only. They can then gradually be introduced to group educational sessions and later to group therapies. Unless their social phobias have been completely resolved, these patients may not do well in Twelve Step programs or other support groups. These individuals often benefit from social skills training, which teaches them important interpersonal skills such as good eye contact, posture, facial expression, voice quality, and appropriate content and fluency of speech. Such training can significantly improve their self-esteem in social situations, thereby reducing the fearful aspects of social phobias. Be aware, however, that even though clients may have overcome their initial fears about the treatment setting, their phobias generally remain. Use less confrontational and more supportive strategies in dealing with socially phobic and agoraphobic clients. Point out that scientific evidence shows that alcohol use does not provide relief from the anxiety associated with phobias, as they may have thought. Obsessive-Compulsive Disorder Obsessive-compulsive disorder is a relatively rare condition in which individuals are bothered by obsessions, that is, recurrent, persistent, and involuntary thoughts, images, or ideas that are perceived as unpleasant or repugnant. These individuals may also engage in compulsions, or repetitive actions, to help them prevent or evaluate some threatening event. They perform these actions with a sense of urgency, but at the same time, they feel the desire to resist such behavior. Typical obsessions include intrusive thoughts of violence, worries over contamination by dirt or germs, or doubts about the safety of people or situations. Typical compulsions include hand-washing, counting, and checking doors or windows to make sure they are locked or secure. Clinical anecdotes suggest that abuse of alcohol and minor tranquilizers is fairly common among those with obsessive-compulsive disorder. In one small study, 6 percent of alcoholics were found to have obsessive-compulsive disorder. 26

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In recent years there have been great advances in the diagnosis and treatment of obsessive-compulsive disorder. Recently clomipramine (Anafranil) was approved for use in this condition. Also, the widely prescribed antidepressant fluoxetine (Prozac) has been demonstrated to be an effective anti-obsessional agent. Techniques have also been developed for exposing patients to troubling situations and teaching them ways to curb their obsessions or compulsions. Reducing symptoms of the disorder usually results in a marked reduction in use of alcohol or other drugs as a coping mechanism. By the same token, reducing alcohol and drug use also improves the client's compliance in effective psychiatric treatment. Both problems must be vigorously addressed in treatment to ensure the best possible outcome. If you encounter a client whom you suspect of having this dual disorder, seek a consultation with an expert. Posttraumatic Stress Disorder Posttraumatic stress disorder (PTSD) arises following exposure to an unusual, highly stressful, psychologically traumatic event. Typically, PTSD results from severe military combat stress or natural or man-made disasters. People who experience rape or assault, sexual abuse, kidnapping, torture, incarceration in concentration or prisoner-of-war camps, floods, earthquakes, or atrocities may develop PTSD. Counselors working with military veterans should be particularly familiar with this condition. People with PTSD have high rates of alcoholism and substance abuse, as do nonmilitary members of their families. 27 (We should note that a controversial report suggested that military veterans who were not exposed to combat have rates of alcoholism and drug abuse equal to those seen in veterans with PTSD. Such a finding calls into question the role of combat stress in the development of chemical dependency in these clients.)28 Victims of PTSD reexperience the stressful event through intrusive and painful images, memories, dreams, or nightmares. Other characteristics include a withdrawal from or reduction in responsiveness to the external world, an exaggerated startle response, hyperalertness, and sleep disturbance. Combat veterans often have flashbacksdissociative episodes in which they feel and behave as if they were currently experiencing the events of a battle. The symptoms of PTSD are frequently worsened by reexposure to situations or activities reminiscent of the original stressor, such as loud noises or other sensory stimuli.

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Vietnam and other combat veterans with PTSD have been described as experiencing depression, distrust and mild paranoia, excessive anger and rage reactions, social isolation, and survivor's guilt. 29 Case History: Roger Roger is thirty-eight years old, married, and the father of two sons. Laid off from his job as a steelworker, he occasionally works odd jobs to supplement his wife's income. Roger is the second of five children. His father was a foreman at the steel mill and is described as a hard-working, hard-drinking, honest and quiet family man. Roger describes his relationship with his parents in positive terms and maintains frequent contact with all family members. Roger was a B student in school and describes his childhood as normal. He occasionally drank alcohol with friends but never used any other drugs in high school. After graduation, he attended community college for one year, and then he quit to take a job in the steel mill. In 1968 Roger was drafted into the army and was sent to infantry school. He was trained as a front-line soldier and sent to Vietnam in early 1969. During his year in Vietnam, Roger was exposed to intense combat. He was involved in numerous firefights, in which he killed at least a dozen of the enemy. Several of his comrades were killed in these battles. Roger started drinking heavily when he was out of combat. He also began snorting heroin and smoking pot, which were freely available, but he preferred booze. He drank primarily to relax and to ''forget about this damned war.'' In the summer of 1969, while on patrol, he heard something drop from the sky. He turned around and spotted a hand grenade on the ground. Just then the grenade exploded, killing his best friend, Pete. Standing just ten feet away, Roger was only slightly grazed by shrapnel, but he was splattered with blood and gore. He was treated at the base hospital for shock. After his discharge from the Army, Roger came home and married his high school sweetheart. Although he returned to work in the mill and took a few night courses at a local college, he rarely socialized with anyone, including his wife. Roger refused to watch movies or television programs about the war. He resisted the efforts of others to get him involved in service organizations or other functions aimed at helping Vietnam vets. Privately, Roger was having constant uncomfortable memories about Vietnam. He kept visualizing his friend being blown apart by the grenade. He could hear the sound as the grenade hit the ground and the subsequent

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explosion. He could feel Pete's hot, sticky blood splattered over his face. He could smell the gunpowder. It was as if he were still there. He would try his best to get rid of these memories, but they would pop into his head whenever anything reminded him of Vietnamand everything reminded him of Vietnam. The sounds of aircraft flying overhead, loud noises, the smell of Asian cookingall triggered memories of his experiences. These memories in turn brought on tremendous feelings of guilt: he made it back home, but others didn't. Roger had frequent nightmares, from which he would awaken in a cold sweat. In his dreams, he relived the firefights. He was haunted by a recurrent nightmare in which he helplessly watched Pete die. As time went on, Roger had increasing difficulties falling asleep and sleeping through the night. He drank alcohol daily in an effort to control his thoughts and feelings about Vietnam, to relax, and to fall asleep at night. Gradually he began getting drunk and aggressive. Several times he got into fights when he heard other people bad-mouthing Vietnam vets. Over the past six years, he has experienced periodic bouts of depression, particularly around the anniversary of Pete's death. When he visited the Vietnam veterans' memorial in Washington, D.C., and saw his friend's name etched on the monument, he experienced a tremendous surge of sadness and rage. He then went on a four-day drunk. In the past year, he has increasingly shut himself off from others. He has had difficulty talking openly with his wife, who reports that Roger "shuts her out" emotionally and never tells her what he's thinking or feeling. His parents, brothers, and sister have noticed changes in Roger in the past several years. They see him as aloof, easily angered, and moody. They worry that he drinks too much. Assessment Criteria DSM-III-R* outlines the following characteristics of posttraumatic stress disorder: 30 1. There exists a recognizable stressful event that is outside the range of usual human experience and that would be markedly distressing to almost everyone. 2. The patient reexperiences the traumatic event, as evidenced by at least one of the following: Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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·

recurrent and intrusive recollections of the event

·

recurrent dreams of the event

·

suddenly acting or feeling as if the traumatic event were recurring

· intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma 3. The patient persistently avoids the stimuli associated with the traumatic event or experiences numbing of general responsiveness as shown by at least three of the following: ·

efforts to avoid thoughts or feelings associated with the trauma

·

efforts to avoid activities or situations that arouse recollections of the trauma

·

inability to recall an important aspect of the trauma

·

markedly diminished interest in one or more significant activities

·

feelings of detachment or estrangement from others

·

restricted range of affect

·

a sense of a foreshortened future

4. The patient experiences persistent symptoms of increased arousal that were not present before the trauma, as indicated by at least two of the following: ·

difficulty falling or staying asleep

·

irritability or outbursts of anger

·

difficulty concentrating

·

hypervigilance

·

exaggerated startle response

·

physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event

5. The disturbance has persisted for at least one month. Assessment Issues The intake process for PTSD clients is frequently accompanied by confusion. These people often experience a spectrum of symptoms such as anxiety, depression, and guilt, as well as substance abuse. Many times they are distrustful and will not freely disclose their experience in combat or talk about some other stressful event; therefore, it is necessary that at intake you specifically ask clients whether they were exposed to military

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combat or whether they have been victims of assault or rape. If your clinic is located where natural disasters or man-made catastrophes have occurred, ask about the client's experience during these events. If possible, examine the client's military discharge record (also known as the DD-214) to verify war history. The accuracy of a client's report of symptoms should also be confirmed by interviewing family members or their collateral informants. The use of psychological testing and clinical consultation is also extremely valuable. The signs and symptoms of withdrawal from chronic alcohol or other drug use, or of any of these anxiety states, can confuse the clinical picture of PTSD. Similarly, people with a prolonged withdrawal syndrome may appear very much like someone with an anxiety disorder. Therefore it's a good idea to wait for a few weeks after detoxification before you make a formal evaluation. Detoxification can usually proceed even before symptoms of PTSD are addressed. However, PTSD clients may be demanding; some have a sense of entitlement that may consume staff members' time and energy and try their patience. Those clients with multiple substance abuse problems may manipulate staff in an effort to receive psychotropic drugs beyond the required amounts. Counseling Issues As counselor, your initial task is to develop a trusting relationship with a PTSD client who may be hostile and suspicious and who may have no desire to "open that old can of worms." You can achieve this goal through warmth, openness, and empathy. In sessions, deal immediately and aggressively with the chemical dependency problem, but take a less aggressive approach in dealing with the underlying traumatic event. To avoid triggering overwhelming anxiety, slowly introduce the topic and gradually expand on it. Educate yourself as much as possible about the nature of the client's stressor. Even counselors with no military experience can treat veterans successfully if they are sensitive and knowledgeable about the war, the military, and combat. Similarly, victims of disasters do best in treatment when their counselors are knowledgeable and empathetic about the traumatic event that had such impact upon their lives. Survivor's guilt is a phenomenon that affects not only PTSD clients, but counselors as well. Such thoughtsinduce feelings of guilt that impede your effec-This could have happened to me; I should have been therecan

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tiveness. Be wary of acting on an impulse to be nice to clients by being less directive and confrontational concerning their chemical dependency. Keep in mind that sobriety is the first step in helping resolve and integrate the traumatic event into your client's life. Clients with PTSD are frequently so preoccupied with their traumatic experiences that they have trouble focusing on problems with chemical dependency. One way to manage this problem is to refer them to a PTSD support group. (In most cases, this will mean a Vietnam veterans group that meets at a community center or a VA facility.) Such a support program should be simultaneous with, but separate from, the substance abuse treatment program. In this structure, clients can work through the traumatic experience in the support group, and focus on their substance abuse problem in the chemical dependency treatment program. Without this two-pronged approach, clients may use one problem as a defensive strategy to avoid dealing with the other. People with PTSD may also have severe difficulties in social, economic, vocational, and marital adjustment. Each of these areas must be addressed in treatment through the use of marital and family therapy, vocational counseling, and referral to appropriate social service agencies to help individuals reintegrate into the mainstream of society. In addition to military veterans, many others experience PTSD as a result of exposure to traumatic experiences such as being a victim of rape, sexual abuse, assault, or chronic exposure to very difficult circumstances. Traumatic experiences appear to be more common among some types of psychiatric illness than others. For example, a significant number of individuals with borderline personality disorder have also been victims of abuse, rape, or other trauma. The emotional turmoil associated with such traumatic experiences may contribute to substance abuse or relapse. Therefore, all clients should be assessed to determine if they have had such experiences so that treatment can address the psychological scars associated with PTSD. In general, however, you should guard against prematurely addressing these issues in depth with clients who are unable to establish a period of stable sobriety for several months or longer. Exploring traumatic issues from the past often raises anxiety that can trigger the client without a foundation of recovery to drink or use drugs. Both psychotherapy and special support groups, such as Survivors of Incest, can help clients work through the trauma. Obviously, you need to have a solid therapeutic alliance with such clients in order to help them explore and work through any PTSDrelated issues.

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Generalized Anxiety Disorder Generalized anxiety disorder (GAD), first described in the 1987 edition of the DSM, is characterized by chronic and excessive anxiety and worries that are unrealistic. GAD usually emerges before age forty and is equally common among men and women. Some experts question whether GAD is a true clinical entity. They cite the fact that GAD often emerges following a major depressive episode and thus may be merely another form of depression. 31 Furthermore, certain other recognized conditions bear a resemblance to GAD, including acute cocaine or amphetamine intoxication, acute and protracted alcohol withdrawal, tranquilizer withdrawal, excess caffeine consumption, and elevated thyroid activity. You will need to rule out any of these other potential causes of anxiety symptoms before assuming that your clients have GAD. The controversial nature of GAD and the absence of good epidemiological data make it difficult to assess its relationship to chemical dependency. Clinical experience, however, suggests that clients who have this disorder are susceptible to abuse of alcohol, barbiturates, and tranquilizers. The case that follows shows how symptoms that appeared to be part of GAD were caused by excessive use of caffeine. This type of "false positive" is not all that unusual among the chemically dependent, given that many use caffeine excessively. A thorough assessment is needed, as well as patience on the part of the evaluator, so that a diagnosis of GAD is not made inappropriately. Case History: Dave Dave is twenty-nine years old, an insurance salesman, and a recovering alcoholic who regularly attends AA meetings. He and his wife, Bridget, have been married for six years and have a three-year-old daughter. Although a good worker, Dave is clearly not a "morning person." To get his day started, Dave would down two cups of coffee with breakfast, drink another mug on the drive to work, and then have another when he got to the office. If around one o'clock he began to fade, it was time for another round of java. Before important meetings, he would prime himself with another cup. He would also have "one for the road" before heading for home in the evening, and he would drink coffee during the evening AA meetings he regularly attended. When Dave's coffee consumption reached seven or more cups a day, Bridget noticed a significant change in Dave's behavior. He was constantly

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worried about making ends meet, despite his successful business. He was also worried that something bad would happen to their child. Bridget reassured him, but this only appeased him temporarily. His behavior seemed to worsen over several months. Dave also noticed some changes in himself. He constantly felt restless and edgy, and sometimes his hands would shake when he tried to sign his name to his clients' insurance applications. His handshake was cold, damp, and clammyhardly an asset for someone in his line of work. He constantly had a severely dry mouth, which he tried to relieve by drinking Classic Coke, another caffeinated beverage. On several occasions, he felt his heart pounding rapidly, which really scared him. By now, Bridget was deeply concerned about her husband's condition. With his constant preoccupation with their finances and their daughter's well-being, and his cranky mood and shaky hands, he appeared to be suffering from some kind of mental disorder. "Probably the stress at work finally got to him!" she thought. She was also concerned that his strange behavior might be the beginning of relapse back into alcoholism. Her best friend stated that Dave should go for an evaluation by a psychiatrist with expertise in chemical dependency. It took Bridget almost a month to work up the nerve to suggest this. When she did, he realized she was so concerned about his well-being that he agreed to go. The psychiatrist asked about his reason for coming, then took a detailed psychiatric history, administered a mental status exam, conducted a family history, and took a comprehensive alcohol and drug use history. When asked about his caffeine consumption, Dave gave some honest estimates. The psychiatrist then smiled and said, "Dave, I was initially concerned that you might have a condition called generalized anxiety disorder. A lot of folks in recovery show signs of this problem. However, I now think that this is less likely. My opinion is that most of your symptoms may be due to excessive caffeine intake. Why don't you try gradually cutting down on your coffee and cola drinking and see if that makes you feel any better," he suggested. "Let's work together on this. I would like you to keep a careful log of all the coffee, tea, and cola you drink each day. Each day, you should reduce your intake until you get down to one or two cups of coffee a day. If you still have these symptoms, then I'm going to have to consider other causes and other treatments. However, I'm confident that this step will help." It took nearly a month for Dave to reduce his coffee consumption. It was especially hard for him to quit sipping coffee at his regular home

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meeting. But Dave worked hard at it and was successful. After a couple of weeks on the new routine, both he and Bridget noticed a big improvement in his behavior. The worrying diminished. He was less irritable with his daughter. He felt calmer and more energetic. His hands were steady, dry, and warm. There were no more palpitations. Dave is now considering eliminating caffeine altogether from his diet. Assessment Criteria The signs and symptoms of GAD are similar to those of panic disorder. However, remember that panic attacks occur in discrete episodes, while the symptoms of GAD persist over a period of time. As the DSM-III-R* criteria state, GAD involves unrealistic or excessive anxiety about two or more life circumstances for a period of at least six months, during which the person has been bothered more days than not by these concerns. If another major psychiatric condition is present, the excessive worry must be unrelated to this other condition. Furthermore, this disturbance should not be related to a mood or psychotic disorder. In addition, at least six of the following symptoms should be present when the client is anxious: motor trembling, twitching, or feeling shaky; muscle tension, aches, or soreness; restlessness; easy fatigability; shortness of breath or smothering sensations; palpitations or accelerated heart rate; sweaty or cold, clammy hands; dry mouth; dizziness or light-headedness; nausea, diarrhea, or other abdominal distress; hot flashes or chills; frequent urination; trouble swallowing or "a lump in the throat"; feeling keyed up or on edge; exaggerated startle response; difficulty concentrating or "the mind going blank" because of anxiety; trouble falling or staying asleep; or irritability. 32 Lastly, the diagnosis is made if it cannot be established that an organic factor such as caffeine intoxication or hyperthyroidism initiated or maintained the disturbance. Assessment Issues These clients typically abuse alcohol, barbiturates, and tranquilizers. However, since general anxiety symptoms look very similar to withdrawal symptoms produced by these drugs or to the effects of stimulant drugs like caffeine, cocaine, and amphetamine, it is important to determine whether or not the client is using these drugs. A good drug and alcohol use history *Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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is critical. Again, since certain medical conditions can mimic this disorder, a good medical consultation is essential. Little is known about how common this disorder truly is, either among people with chemically dependency or among the general population. Medication Issues Although clients with chemical dependency and GAD may respond to tranquilizers such as Valium, they are predisposed to develop addictive problems with these compounds, which makes their long-term use inadvisable. Furthermore, among recovering clients, use of such medications may stimulate cravings and precipitate relapse. Now available is a new class of anxiety-reducing medications such as buspirone (BuSpar) that appear to be effective in treating GAD yet have no abuse potential and do not stimulate cravings. The major drawback with these compounds is that two or more weeks may elapse before the patient notices any relief. Consequently, clients using this medication may need a lot of contact and encouragement during early stages of treatment while they wait for the effects to appear. Counseling Issues Counsel clients with GAD against relying solely on medication to relieve discomfort. Teach them relaxation techniques to control their anxiety. Recommended methods include Jacobson's relaxation training technique, autogenic training, biofeedback, and transcendental meditation. 33 Although anxiety symptoms may persist, these methods provide the client with alternative strategies for coping with stress without resorting to alcohol or other drugs. The cognitive, interpersonal, and lifestyle techniques discussed earlier can also be used with clients who have GAD. Outpatient Aftercare As is true for chemical dependency clients, outpatient psychiatric or psychological follow-up is usually necessary for treatment of anxiety disorders. Clinical evidence suggests that abstinence improves, but does not entirely eliminate, symptoms of anxiety. Similarly, treatment of the anxiety disorder may improve, but not eradicate, substance abuse. Thus a combined approach that addresses both disorders and provides for aftercare is of greatest benefit to these clients. Placement in a halfway house is generally not indicated for these clients

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unless they have a history of responding poorly to combined substance abuse and psychological treatment or if they are without any abstinenceoriented social support network. Use of Medications for Substance Abusers with Anxiety Disorders Anxiety disorders may have a biological basis. The responsible, closely supervised use of medications to relieve symptoms can treat the primary condition while it advances the client's recovery from chemical dependency. Occasionally clients with bona fide GAD will be given benzodiazepines by nonpsychiatric physicians who may be unaware of the client's alcoholism or substance abuse history. Be ready to call on the skill of your psychiatric consultants to wean such clients off these abused drugs. Consultation with the prescribing physician may also be helpful. Occasionally a catastrophic event such as the loss of a loved one worsens the client's anxiety. Such circumstances sometimes warrant the temporary use of medications during the crisis, so long as dosages are carefully monitored. However, even well-controlled quantities of benzodiazepines should not be prescribed for longer than one month. These clients should be seen and evaluated frequently and asked to return any unused medications once the crisis has been resolved. The use of sleeping medications frequently arises as an issue for clients with anxiety disorders. Although clients recently detoxified from alcohol will experience some sleep disturbance for about three months, 34 as a rule, sleeping medications are not indicated. There are two reasons for this: First, these agents have addictive potential. Second, sleeping medications delay, rather than hasten, the return of normal sleep patterns. The anxiety disorder for which medications are indicated is panic disorder, with or without agoraphobia. Panic attacks generally respond very well to treatment with antidepressants such as imipramine (Tofranil), desipramine (Norpramin), or phenelzine (Nardil). These medications do not carry a potential for abuse. Recently a benzodiazepine, alprazolam (Xanax), has been shown to be effective in treating panic attacks; however, like other drugs in its class, it has potential for addiction and should not be prescribed for alcoholics and other substance abusers. Remember that some members of self-help groups oppose the use of medications in any circumstances. Before referring your clients to such a program, make certain that the clients know that some group members may oppose any use of medications, including those necessary in treating anxiety disorders. Agoraphobics, for example, have the best chance to

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overcome their phobia when the panic attacks subside, which requires the judicious use of pharmaceutical agents. Twelve Step sponsors need to support these individuals rather than criticize or undermine them; they must recognize that discontinuing medication could result in a return of the panic attacks and complete relapse to substance abuse. A group of physicians who are members of Alcoholics Anonymous wrote a pamphlet called The AA MemberMedications and Other Drugs. 35 This booklet spells out the difference between pill popping and the use of appropriate medications under a doctor's supervision. We recommend that all recovering individuals using medications, as well their Twelve Step sponsors and their counselors, read this important piece of literature. Summary Anxiety disorders are closely associated with chemical dependency. Many patients initially use alcohol and drugs to lessen their anxiety, only to find they develop a chemical dependency. Anxiety symptoms often increase when these individuals first stop using alcohol and drugs. For some, symptoms persist and even worsen the longer they are free of alcohol and other drugs. A variety of cognitive, psychological, interpersonal, and lifestyle interventions can be used, depending on specific symptoms the patient is experiencing. Nonaddictive medications can be used to treat some of the anxiety disorders, particularly when the patient's functioning is seriously impaired by symptoms of the disorder.

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Chapter 9 Schizophrenia and Chemical Dependency An Overview Schizophrenia is one of the most serious and debilitating of the psychiatric conditions. People with this dual diagnosis are among the most challenging to treat. According to Rounsaville and colleagues, the severity of the schizophrenia is the most accurate predictor of treatment outcome among these dual-disordered clients. 1 Although specialized treatment programs are increasingly used for this population, there is a lack of empirical data regarding their effectiveness. As we will explain in this chapter, these clients are usually best treated in homogeneous groups by caregivers who are familiar with both diagnoses. Prevalence The early literature focused mainly on alcohol abuse among schizophrenics.2 More recent studies show that drug abuse is also common among individuals with schizophrenia.3 The National Institute on Mental Health ECA survey found the prevalence of schizophrenia to be 1 percent among the general population. Rates of schizophrenia among the chemically dependent were found to be almost four times that found in the general population. The ECA survey also found the prevalence of chemical dependency among the general population to be 16.4 percent, while the rate of chemical dependency among individuals with schizophrenia is 47 percent.4 Studies of clinical populations also show higher rates of schizophrenia among people with chemical dependency; by the same token, higher rates of chemical dependency occur among individuals with schizophrenia than would be expected by chance. In one study, for example, the rate of schiz-

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ophrenia among cocaine abusers was 16.7 percent; among opiate abusers, it was 11.4 percent; and among marijuana abusers, the rate was 6 percentall much higher than the rate found among the general population. 5 Relationship Between Schizophrenia and Chemical Dependency Both of these disorders run in families, but they appear to be inherited separately.6 Many experts believe chemical dependency in schizophrenics begins as self-medication for relief of psychotic or other symptoms of this disorder.7 Alcohol, for example, produces relief (at least in the short term) from the muscle tension and severe anxiety experienced by schizophrenics; however, the problems that arise from long-term substance abuse far outweigh these brief gains. For instance, the use of chemicals may exacerbate symptoms or trigger a psychotic break. Researchers have consistently found a higher incidence of schizophrenia among family members than among the general population. Studies show that the condition is more common among children who were born to parents with schizophrenia and then adopted and reared by parents who did not have the disorder. Also, if one of a pair of identical twins has the disorder, the odds are high that the other will develop it as well. Clearly, genetic factors are involved, although research indicates that environmental factors can also contribute to the development of schizophrenia. Schizophrenia is treated with medications called neuroleptics (such as Thorazine, Prolixin, Haldol, Mellaril, or Clozapine). Studies show that chronic use of alcohol by schizophrenics results in unstable and inadequate therapeutic blood levels of medications, which may lead to an increase in psychotic symptoms. Characteristics of Schizophrenia Schizophrenia is not a single disorder but a group of different disorders with similar characteristics. The following are the essential features of schizophrenia:8 ·

the presence of psychotic features during the active phase of the illness

· characteristic symptoms involving multiple psychological processes (alteration in the form and content of thought, disturbance of sensory perception and affect, impaired sense of self, etc.) ·

deterioration from a previous level of functioning in such areas as work, social relations, and self-care

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·

onset before age forty-five

·

a duration of at least six months

During active phases, schizophrenia usually involves delusions, hallucinations, and disturbed thinking. Delusions are false beliefs, generally of negative character. Often people with schizophrenia are convinced that other people or outside forces want to observe, persecute, control, or injure them. For example, a patient might believe that someone reading the news on television is mocking him or giving him some highly personal message. Delusions common among schizophrenics include thought broadcasting (the belief that others can hear one's thoughts), thought insertion or withdrawal (the belief that someone or something is beaming ideas directly into the brain or taking them out), and external control (the belief that someone is controlling behavior from the outside). The delusions associated with schizophrenia are fixedthat is, they cannot be disputed or displaced by logic. 9 Hallucinations are perceptions that arise without connection to an object or a stimulus in the external environment. They may involve any of the senses, but the most common hallucinations occurring in schizophrenic disorders are auditory in nature. Typically, auditory hallucinations take the form of a voice coming from outside one's head, providing a running commentary on the person's thoughts or behavior. Some patients report hearing two or more voices conversing with each other.10 A disturbance in form of thought (sometimes called a formal thought disorder) is characterized by loosening of associations. Ideas shift suddenly from one subject to another, in a kind of incoherent stream of consciousness. Afflicted people are unaware that their topics are unrelated or that their conversation is rambling and confusing to other people. Another symptom of a formal thought disorder, poverty of content, describes speech that is inadequate in amounts, conveys little information, or is vague to the point of incomprehensibility.11 The affect of a person with schizophrenia is often blunted or flat. The voice is monotonous and the face immobile. Or the affect may be inappropriate and marked by sudden, unpredictable changes. For example, outbursts of anger or laughter may occur without any obvious connection to the current situation.12 Other psychological or behavioral characteristics of these disorders include loss of ego boundaries (extreme perplexity about one's identity or the meaning of existence); a tendency to withdraw from the outside world

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into a rich yet bizarre fantasy life; and disturbances in motor activity, such as catatonia (maintaining rigid postures for long periods), bizarre mannerisms, grimacing, or waxy flexibility (remaining in an unnatural position with no apparent difficulty, such as raising one arm and leaving it suspended there for a long time). 13 According to the DSM-III-R, schizophrenia occurs in three phases: prodromal, active, and residual.14 During the prodromal phase, people with this disorder withdraw from social activity, have trouble carrying out their roles in life, and neglect personal hygiene. The active phase is characterized by delusions, hallucinations, loosening of associations, and incoherent speech with poverty of content and marked illogical thinking. The residual phase follows and is similar to the prodromal phase, with a blunt or flat affect and impairment in role functioning. Psychotic symptoms, such as delusions or hallucinations, may be present, but they are no longer accompanied by strong affect. After this phase people rarely return to their premorbid level of functioning, showing deterioration instead. Each recurrence of an acute episode is followed by increased deterioration. While the onset of schizophrenia may occur in middle or late adult life, the most common onset is during adolescence or early adulthood. Before a diagnosis can be made, the illness must persist for six months. This is important to distinguish it from a number of other disorders, such as psychotic conditions caused by alcohol or drugs. People experiencing an acute phase of schizophrenia often require psychiatric hospitalization to ensure that their basic needs of safety, nutrition, and hygiene are met. They also need to be protected from the consequences of impaired judgment or of their response to delusions and hallucinations. For example, such individuals may respond to voices commanding them to harm themselves or others by jumping off a bridge or driving recklessly. Neuroleptic medications decrease the intensity of the psychotic processes. In most cases, patients will remain on these drugs for the rest of their lives. Some individuals, however, are able to take low doses of the medications or stop taking them entirely for periods of time. Subtypes There are several subtypes of schizophrenia, each defined by the predominant clinical symptoms. The disorganized type is marked by incoherent, flat, or silly affect; people with this type usually show no systematized delusions.15 Associated

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with this disorder are grimaces, bizarre mannerisms, hypochondriacal complaints, extreme social withdrawal, and other oddities of behavior. The paranoid type is characterized by persecutory or grandiose delusions or by hallucinations. 16 Associated features include anxiety, anger, argumentativeness, and violence. There may be doubts about gender identity or extreme fear of being perceived as homosexual by others. The impairment in functioning may be minimal, since behavior is not disorganized to the extent seen in other types of schizophrenia. The catatonic type is marked by psychomotor disturbance that may involve stupor, negativism, rigidity, excitement, or posturing. Waxy flexibility and mutism are particularly common.17 During catatonic stupor or excitement, people with this type of schizophrenia need careful supervision to avoid hurting themselves and others. Medical care may be needed because of malnutrition, exhaustion, or self-injury. The residual type describes cases in which the patient has a history of schizophrenic episodes but currently has no prominent psychotic symptoms.18 Emotional blunting, social withdrawal, eccentric behavior, illogical thinking, and loosening of associations are common. If delusions are present, they are not prominent; nor are they accompanied by strong affect. The undifferentiated type shows prominent psychotic symptoms that cannot be classified in any category or that meet the criteria for more than one type of schizophrenia. 19 Case History: Fred Fred is forty-eight years old, a veteran who was first diagnosed with schizophrenia when he was twenty-four, which resulted in a medical discharge from the army. Unemployed for the past eight years, he now lives in a rooming house where he has his own room with a bed, a television, and a chair. There are no cooking facilities, and the bathroom is shared by other residents. Although Fred frequently sees the six others who live in the house, he has no relationship with any of them. He keeps to himself, spending most of his time watching television or looking out the window. ''It's better to keep to yourself,'' he tells his counselor. "People are always trying to get me. I just stay awaybut I keep my eye on them." An only child, Fred was frequently lonely and unable to make friends. His peers thought he seemed a little odd, and they often teased and bullied him. As a result, he avoided them. Fred's father, a successful businessman, ruled the family with an iron hand and showed little interest in Fred when

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he was growing up. His mother responded to her husband's authoritarian control with total submission. Although she was never cruel or antagonistic toward Fred, no closeness developed between them. This contributed to his loneliness; he wondered if something might be wrong with him because he felt his parents did not love him. He tried hard to please them but could not do well enough in school or in sports to earn their praise. Because he spent so much time alone, Fred created a rich fantasy life for himself. In this world, in contrast to the real world, Fred was special and everyone admired and paid attention to him. His mother often noticed that Fred smiled or laughed for no apparent reason, but when she would ask why, Fred refused to explain. His father observed how insecure his son was and tried to make him stronger by criticizing and belittling him. The more his father pushed, the more Fred withdrew into his private world. Fred graduated from high school, then joined the army because his father believed it would help him to be a "real man." It was there that he had his first psychotic episode. It occurred while Fred was stationed in Germany, working as a clerk in charge of inventory at a food warehouse. He began to have strange thoughts. He suspected some food cans were really surveillance equipment put there to get information about him. Initially, he told no one about these beliefs, and as time progressed, he began to hear voices he thought were being broadcast from certain cans. He believed he was given these messages because he had been chosen for a special mission. As a result, he spent most of his free time in the warehouse, not sleeping, not eating, and failing to perform his other duties. One day his commanding officer found him in a disheveled state, talking aloud to himself about "the special mission." Fred was hospitalized for three months. Upon release from the hospital, he was discharged from the service. The voices he heard never really left him; instead, they continued to speak to him wherever he went. Sometimes they were soft and he could ignore them, but at other times he could not concentrate on anything but the voices. The medication prescribed by his psychiatrist produced a troubling side effect: aching muscles. Fred discovered that alcohol provided some relief. After that his consumption, already heavy, increased further. Beer was considered a man's drink, so when he was using alcohol, he also felt like a real man. At first he hung out with a hard-partying group at a local bar. As his alcoholism progressed, he drank alone in his apartment. One night the neighbors called the police to investigate the noises they

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heard coming from his room. The police found an extremely disheveled Fred in a filthy room cluttered with beer cans and other garbage. Fred was incoherent and drunk. He rambled on about a special mission and misidentified the police as some foreign government agents who had come to bring him special orders. He was taken to the psychiatric hospital, where he was stabilized from his psychotic symptoms and detoxified from alcohol. Upon release from the hospital, however, Fred continued with his excessive drinking. Alcohol use inevitably caused him to stop taking his medication, leading to a decline in function and to another round of detox and hospitalization. Eventually Fred wound up in the state mental hospital. Assessment Criteria The specific criteria for schizophrenia as outlined in DSM-III-R* include the following: 20 A. Characteristic psychotic symptomseither (1), (2), or (3)are present in the active phase for at least one week (unless the symptoms are successfully treated). 1. two of the following: a. delusions b. prominent hallucinations (throughout the day for several days or several times a week for several weeks, each hallucinatory experience not being limited to a few brief moments) c. incoherence or marked loosening of associations d. catatonic behavior e. flat or grossly inappropriate affect 2. bizarre delusions (i.e., involving a phenomenon that the person's culture would regard as totally implausible, such as thought broadcasting, being controlled by a dead person, and so on) 3. prominent hallucinations [as defined in 1b] of a voice speaking content that has no apparent relation to depression or elation, a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other B. During the course of the disturbance, functioning in such areas as *Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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work, social relations, and self-care is markedly below the highest level achieved before onset of the disturbance (or when the onset is in childhood or adolescence, failure to achieve expected level of social development). C. Schizoaffective disorder and mood disorder with psychotic features have been ruled out; i.e., if a major depressive or manic syndrome has ever been present during an active phase of the disturbance, the total duration of all episodes of a mood syndrome has been brief relative to the total duration of the active and residual phases of the disturbance. D. There have been continuous signs of the disturbance for at least six months. The six-month period must include an active phase (of at least one week, or less if symptoms have been successfully treated), during which there were psychotic symptoms characteristic of schizophrenia (symptoms in A), with or without a prodromal or residual phase. E. It cannot be established that an organic factor initiated and maintained the disturbance. F. If there is a history of autistic disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present. Staff Issues Clients with schizophrenia and a substance abuse problem challenge the skills and resources of the treatment facility. Staff members who have experience with psychiatric clients are an essential part of the treatment team. The team should include psychiatrists, psychologists, psychiatric nurses, and psychiatric social workers who recognize early signs of psychotic behavior and are able to intervene appropriately. For treatment programs whose staffs lack such expertise, ongoing training and supervision are recommended. Staff members must be aware that with these patients, treatment goals are usually achieved much more slowly than with nonschizophrenics. Goals and expectations that, are too high and unrealistic set clients up for failure. As a counselor, you should be prepared to provide positive reinforcement, encouragement, and support. Failure will further injure the client's already fragile ego and frustrate the clinician. Acknowledge and resolve any negative feelings and reactions you have about working with these clients. Such feelings can interfere with the therapeutic relationship and thwart improvement.

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Assessment Issues Counselors in chemical dependency programs are seldom asked to assess clients in whom the diagnosis of schizophrenia has not yet been made. Most of these clients have a longstanding connection with psychiatric treatment facilities, have been diagnosed, and are on medication. However, some clients may present themselves for chemical dependency treatment on their own or after they have been referred by a psychiatric treatment team. In either case, it is important that you learn to identify the signs of schizophrenia that suggest the need for further assessment by a psychiatrist. Following is a review of some of those signs. Generally, people with this disorder have a strange, aloof, or odd ambience about them. This may be very subtle, yet you will no doubt sense that something is different. Some clients will appear dirty or slovenly or dressed in strange clothing. In addition to physical appearance, certain abnormal behaviors and beliefs suggest schizophrenia. One of our clients, for example, wore a piece of copper wire on his wrist because he believed it protected him from the "harmful microwaves" in the room. Paranoia, the irrational belief that something or someone is out to harm an individual, is also frequently seen with schizophrenic clients. They may believe that the CIA, the Mafia, or a specific person is out to get them. They may inspect the room or overreact to sounds that others may not even notice, such as the air conditioner or a door closing down the hall. If they speak openly about their paranoid beliefs, their thinking is easily recognized as psychotic. Others are more guarded, however, and will give only short answers or no answers at all. You may feel that you have to "pull teeth" to get the information you seek. Some clients appear to be responding to something other than the environment or the conversation at hand during the clinical interview. This behavior may include looking away or staring at no one or nothing in particular. The client may at times smile or murmur unintelligible words that do not fit the context of the current conversationa sign that hallucinations may be present. Be observant, because these clients are not always willing to describe their thinking or current experiences. Another important clue, of course, is if clients tell you they are taking one of the neuroleptic medications. If any of these signs are present, consult with a psychiatric expert. Ask clients specifically about their use of alcohol or other substances and about their psychiatric and medical history. Supplement your infor-

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mation by speaking with family members and reviewing medical records, because people with schizophrenia are not always able to provide essential information, especially in the acute phase of the illness. If these resources are not available, you will need to rely on the clinical interview, the mental status exam, and behavioral observations to determine the nature of the case and formulate treatment goals. Even with good consultants, the diagnostic process may take some time. The following table differentiates among three common diagnoses that must be considered for patients with psychotic-like symptoms: alcohol hallucinosis, delirium tremens,and schizophrenia. As the table shows, all three of these have the feature of hallucinations in common, but the correct diagnosis is needed to ensure proper treatment. TABLE 9.1 COMPARISON OF ALCOHOL HALLUCINOSIS, DELIRIUM TREMENS, AND SCHIZOPHRENIA ALCOHOL DElERIUM SCHIZOPHRENIA HALLUCINOSIS TREMENS ONSET Forty-eight Seventy-two Unrelated to hours after hours after alcohol intake; last drink last drink late teens or early twenties HALLUCINATIONS Auditory Auditory and Auditory; visual rarely visual PREMORBID Unrelated to Unrelated to Impairment CONDITION disorder disorder related to disorder ORIENTATION TO Oriented Disoriented Oriented PERSON-PLACETIME COURSE Resolves within Resolves within Chronic course a week of last three to five with drink days deterioration MEDICATIONS Antipsychotic Benzodiazepines Antipsychotic drugs optional for three to five drugs, long-term for up to seven days need days

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Once you have completed the assessment process, you can develop a treatment plan. Not only will the psychiatrist make the diagnosis, but he or she will also facilitate hospital admission when indicated. Some clients who need hospitalization refuse to go voluntarily. During the acute phase of their illness, when judgment is impaired, they may be unaware of the need for treatment and may not cooperate. Commitment procedures may be needed to provide safe and appropriate treatment. Educate yourself about local laws regarding commitment procedures for psychiatric evaluation and treatment. You may be called on to initiate or coordinate such proceedings. Detoxification If detoxification is necessary, then in most cases, psychiatric hospitalization is required. Behaviors associated with schizophrenia make it difficult for staff in medical detoxification settings to deal adequately with these clients. The goal of detoxification is to provide medical safety for the client during the process of withdrawal. One of the major concerns in detoxification from alcohol is the possibility of seizures, which can be fatal if not prevented or treated properly. Neuroleptic medications also increase the potential for seizure. Thus, in most cases, medically supervised detoxification is recommended. After detoxification, clients need appropriate psychiatric care and stabilization. During this phase, medications are adjusted by physicians, and knowledgeable professionals provide the psychiatric care needed. As stabilization occurs, the staff should begin talking with the clients about their substance use problem. Plans should be formulated for continued treatment following discharge. Aftercare is most appropriately provided in a dual diagnosis program with professionals trained to address this particular combination of disorders. Treatment Issues and Services A number of treatment interventions are available for clients with schizophrenia and chemical dependency. These include supportive and educational approaches that help clients improve skills in daily living, monitor psychotic symptoms, avoid substance use, build a recovery network, and comply with treatment. Techniques that call on clients to explore their

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past or examine their feelings are less appropriate. We recommend the use of specialized dual diagnosis programs, when feasible, since more traditional addiction treatment programs may cause anxiety and may be emotionally overwhelming. However, you can do a great deal for these clients if you keep in mind their special needs and problems. Chemical Dependency Rehabilitation Programs Clients with schizophrenia may benefit from a traditional drug and alcohol rehabilitation program, but generally this type of care is not recommended. These traditional approaches frequently conflict with standard treatments for schizophrenia. We address specific treatment approaches later in this chapter. Dual Diagnosis Treatment Programs Over the past several years, treatment communities have made great strides in working with clients with dual diagnoses. Many chemical dependency treatment programs will now accept individuals who are using psychiatric medications, as long as their condition has been stabilized. Such programs, however, may not be tailored specifically for clients with schizophrenia. Evaluate any such programs carefully before referring clients to them. The need for specialized programs can be seen clearly by comparing the clinical approaches used for chemical dependency with those used in schizophrenia. TABLE 9.2 COMPARISON OF CLINICAL APPROACHES RECOMMENDED FOR RECOMMENDED FOR TREATMENT TREATMENT OF CHEMICAL DEPENDENCY OF SCHIZOPHRENIA 1. Break through denial 1. Prevent increased anxiety 2. Confront about addiction 2. Do not confront about illness 3. Educate about addiction 3. Clients don't learn easily 4. Encourage expression 4. Major emphasis on of feelings expression of feelings not recommended 5. Confront behaviors 5. Can't tolerate confrontation

Page 163 RECOMMENDED FOR TREATMENT OF CHEMICAL DEPENDENCY 6. Intensive group therapy 7. Use no mind-altering drugs 8. Love is important vehicle for recovery 9. Insight-oriented one-to-one treatment 10. Can use Antabuse 11. Can use a sponsor; much personal self-disclosure 12. Break down defenses

RECOMMENDED FOR TREATMENT OF SCHIZOPHRENIA 6. Can't handle intensity; use supportive approach 7. Neuroleptics are indicated 8. Patients withdraw from groups 9. No intense one-to-one relationships 10. Antabuse contraindicated 11. Finds it harder to tolerate intense relationships and to self-disclose 12. Support existing defenses

Addiction clients are well defendedthat is, they can protect their egos, often using rigid defenses such as denial and projection. The goal of treatment is to break down these defenses and replace them with healthier ones. One method for doing so includes raising the individual's anxiety with techniques such as confrontation, intense group therapy, self-revelation, and expression of feelings. People with schizophrenia, however, have more fragile, less defended egos. Treatment approaches must therefore avoid increasing anxiety (and possibly contributing to psychotic symptoms) and instead should support the defenses present. Education Educating patients about the causes and effects of dual disorders, as well as strategies for recovery, is an important aspect of treatment. However, there are differences in the educational philosophy of caregivers in the various specialties. The chemical dependency treatment field works to increase clients' information about drugs and alcohol and their many effects on the individual and family. Programs use lectures, movies, books and pamphlets, and speakers to educate individuals about the negative aspects of substance abuse. In inpatient settings, clients are often bombarded with information about addiction and recovery.

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Schizophrenics, in contrast, do not react well to being "bombarded." Materials presented in a simple, concrete, and repetitive mannerand in small dosesare usually more helpful. Some professionals have found unique and creative ways to educate clients. Games based on familiar TV programs such as "Jeopardy!" or "Wheel of Fortune" provide a fun, low-anxiety method of educating clients about chemical dependency and mental illness. With "Jeopardy!" for example, the questions and answers all relate to knowledge about addiction and mental illness. Clients' schizophrenic symptoms must be relatively well controlled before education groups are used. If hallucinations are present, they must be controlled to a degree that they do not interfere with the individual's ability to concentrate in educational groups. If the voices are too intense, clients cannot profit from the educational sessions or meet other demands of the treatment program. Reassess the intensity of clients' symptoms regularly, since symptoms and their impact on function may wax and wane. This may be done by observing clients' behavior, speech, and level of comfort. Encourage clients to monitor and discuss such symptoms as hallucinations or delusions. Minimize Exploration of the Past In treating mental disorders, you usually work with clients to explore the past so as to increase their insight and control over behavior. With schizophrenia, however, memories may be distorted beyond recognition. Many people with this disorder are confused about the past or are unable to recall periods of time. Probing the past risks increasing their anxiety and may be counterproductive. In your sessions, try to focus more on current concerns and issues in daily living. Minimize Probing for Feelings Treatment for chemical dependency often focuses on helping clients become aware of their feelings and on bringing those feelings to the fore. The same is not true in treating schizophrenia, however. With these patients, focusing on internal emotions can increase their anxiety and discomfort. This is not to say that the counselor should avoid all discussions of feelings but to suggest that you avoid pushing clients too hard in this direction. Like other clients, people with schizophrenia may need support and help in coping with anger, depression, or other feelings.

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Focus on Behaviors One of the most important things you can do to help these clients is to work on concrete behaviors, such as taking medications as prescribed, attending recommended treatment sessions or support group meetings, structuring time, and coping with day-to-day living issues. Suggest clients learn concrete strategies to cope with their desire to use alcohol or drugs. AA and NA slogans are effective ways of focusing on behavioral changes that will be helpful in recovery. Dealing with Psychotic Symptoms Psychotropic medication eliminates or controls symptoms of schizophrenia. However, some clients using these agents continue to experience persistent symptoms. Monitor these patients carefully; if symptoms erupt or worsen, refer the patients to the treating psychiatrist, who will determine whether a regimen change or hospitalization is needed. If your client is hearing voices, try to find out what the voices are saying. In a gentle and accepting way, ask: ''Are the voices telling you to harm yourself or someone else?'' If the client says that he or she does not feel safe, or if you are concerned about the client's safety, hospitalization may be needed. Ask, too, about substance use, since alcohol or street drugs used after a period of abstinence can trigger or worsen psychotic symptoms. Don't argue with clients about their psychotic symptoms. Never, for example, make such remarks as "You don't hear voices; they're just in your head." Instead, regard such symptoms as signs that the client's anxiety level has increased. Psychotic symptoms may exacerbate suicidal thoughts or behaviors; if these emerge, evaluate the client to determine whether hospitalization is needed. Focus on Life Skills Help with daily living skills is especially beneficial for clients with schizophrenia. Some need to learn how to plan leisure activities, dress appropriately, wash clothes, take care of an apartment, shop, cook, use public transportation, manage money, use community resources, or apply for social benefits (medical care, housing, economic help, etc.). Work with clients to help them establish regular routines. Check day is a high-risk time for individuals with schizophrenia and addictions. Help clients receiving disability or public assistance checks to

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structure their time and to plan carefully how to use their money. Also, discuss ways that they can cope with the drug cravings that are triggered by receiving money. Interpersonal Relationships and Recovery Networks Because they often withdraw from others, chemically dependent clients with schizophrenia may need help developing or restoring interpersonal relationships. Participating in treatment groups or self-help groups can help them structure their day and provide them with valuable socialization experiences. Partial hospitalization programs provide a number of activities such as discussion groups, activity groups, social outings (bowling, movies, picnics), or special classes on planning budgets or cooking. Such events fill time that would otherwise be spent drinking, using drugs, or in isolation from others. Role-playing is effective in teaching clients how to interact or communicate with others. It provides an opportunity for an individual to try out new behaviors such as asking for a date, giving a compliment, requesting help, interviewing for a job, resisting pressure to use alcohol or drugs, or refusing to give money to manipulative fellow addicts. Case Management Issues Clients whose illness has led to many hospitalizations and to significantly impaired functioning may need the services of a case manager. As a counselor, you may be overwhelmed by the need to help clients locate housing, find residential programs, or manage other financial, behavioral, or social needs. Bringing in a case manager, whose sole job is to deal with these issues, can ease your burden and help clients at the same time. Medications Therapy with neuroleptics is the treatment of choice in schizophrenia; patients need drug therapy to bring symptoms under control so that they can take advantage of other counseling services. Teaching clients to use medication appropriately is a major goal of treatment. Instruct your clients that alcohol or drug use will interfere with the effectiveness of their medications. Sometimes clients will argue that drug use relieves anxiety or psychotic symptoms; educate them about long-term adverse consequences of continued substance abuse. Also emphasize that withdrawal from medications may be disastrous. Be ready to help clients anticipate and deal with members of support

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groups who try to influence them to stop taking medications. Role-playing is an excellent way for clients to develop the skills and confidence for coping with this potentially stressful situation. Use of Treatment Groups A common treatment approach for people with chemical dependency is the use of intensive and confrontational group therapy. This approach is not appropriate for clients with schizophrenia. A supportive, educational, structured, and less intense group approach is recommended. In group sessions, do not expect schizophrenics to discuss their innermost feelings or push clients to be open about personal problems. Instead facilitate clients' participation by creating a safe atmosphere in the group. Discuss behaviors rather than feelings. Focus on the present. Address specific issues of everyday living instead of unconscious motivations for past behavior. Relapse Clients need to know that relapse is a part of the natural course of schizophrenia. Relapse is not a function of willpower; it happens even to clients who comply perfectly with treatment. Accepting the reality of relapse is as important in dealing with schizophrenia as it is in dealing with chemical dependency. Some of your clients may do well in recovery from chemical dependency, only to find their psychiatric symptoms waxing and waning. This uneven progress may confuse and trouble them. Discuss the issue with clients. Encourage them to maintain abstinence during periods when psychiatric symptoms are present. Relapse prevention strategies are discussed in detail in chapter 11. Family Involvement Understandably, families of dual-diagnosed schizophrenics are usually highly stressed and frustrated in their attempts to help the ill member. Therefore, it is important that families be involved in treatment throughout the continuum of care, not only to support the patient, but to get support and help for themselves. Refer families to Al-Anon, Nar-Anon, or one of the support groups sponsored by the National Alliance for the Mentally Ill (NAMI) for families of psychiatric clients. Psychoeducational programs and family therapy are very helpful interventions as well. For example, some parents are devastated when their bright son or daughter has a first episode of schizophrenia and never

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returns to previous levels of functioning. In such cases, parents may need help grieving the loss of their child as he or she once was. Treatment provides an opportunity for parents and other family members to explore their feelings and concerns. Families should also be taught how to identify early relapse symptoms that may call for changes in medication or rehospitalization. A helpful intervention is psychoeducational family treatment, an approach initially developed by Anderson, Reis, and Hogarty for the treatment of schizophrenia. 21 This approach involves three phases. In the first phase, the clinician connects with family members to verify and validate their family's experiences with the ill member. Family strengths are emphasized and the family is given hope that change is possible. In the second phase, the family takes part in a four- to six-hour psychoeducational group workshop in which the patients participate. The workshop provides information and outlines positive coping strategies for dealing with problems associated with schizophrenia. The third phase involves applying these strategies in day-to-day life to prevent the illness from dominating the family's world. This approach has been used with other types of disorders and can easily be adapted for families of people with dual diagnoses. Extended Residential Care The client with chemical dependency and schizophrenia who lacks a supportive social network is a potential candidate for a halfway house or extended treatment program. Such programs must have a staff knowledgeable about schizophrenia and must have access to psychiatric consultation. When selecting the treatment facility, note the attitude of the staff members and the type of program offered. Halfway houses that are supportive and not confrontational can be useful. Chemical dependency therapeutic communities are not recommended for this population; the most appropriate are dual diagnosis programs that are designed specifically for clients with this combination of disorders. Outpatient Treatment Outpatient treatment should focus on both aspects of the dual diagnosis. Clients need constant monitoring to assess progress, compliance with medication, presence of persistent symptoms, use of alcohol or drugs, and issues pertinent to daily living. Any of the issues outlined in previous sections may be addressed in outpatient treatment. Family involvement should also be a routine part of such treatment.

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Partial Hospital Programs Clients with this dual diagnosis often benefit from day hospital or partial hospital programs. These programs provide a setting in which issues of chemical dependency and schizophrenia can be addressed in specialized treatment tracks. Weekend and evening treatment programs and on-site self-help meetings are recommended as additional measures of support and structure. Self-Help Groups Support groups such as Double Trouble, Chemical Abusing Mentally Ill (CAMI), Substance Abusing Mentally Ill (SAMI), or MISA (Mentally Ill Substance Abusers) help meet the special needs of individuals with schizophrenia and chemical dependency. Mental health groups such as Schizophrenics Anonymous or Recovery Inc. also can help. As we have stated, some individuals in AA or NA groups may oppose the use of any medication, including those used for psychiatric illness; these people tend to lump appropriate medications together with those that have been abused. The use of psychiatric medication may not be an easy issue to discuss in a recovery group that is not focused on dual disorders. Advise your clients who are taking medication to be discreet about sharing this fact. Train them in ways to respond to pressure from others who want them to stop using medications. Clients with paranoid schizophrenia may be unable to benefit from Twelve Step discussion meetings that require a lot of self-disclosure; they might be better off in groups that offer speakers and lectures. Clients with histories of religious delusions may have trouble applying the Twelve Steps that deal with spirituality. Other meetings such as STEMSS (Support Together for Emotional and Mental Serenity and Sobriety), designed specifically for schizophrenia or persistent mental illness, are helpful. Summary Schizophrenia, one of the most debilitating of the psychiatric illnesses, brings much suffering to patients and families, and a substantial number of people with this disorder also abuse alcohol or other drugs. Substance abuse complicates recovery and decreases the efficacy of the psychotropic medications needed in treatment. Relapse of one illness can provoke relapse of the other. Special dual diagnosis programs are recommended for this population. Because of the chronicity and severity of these dual disorders,

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counselors should establish realistic expectations for treatment. Success often comes in small steps. As adjuncts to therapy with neuroleptics, clinical interventions should be supportive and educational in nature. They should focus on helping clients cope with persistent symptoms of mental illness, improve daily function and living skills, cope with the urge to use alcohol or drugs, develop routines and structures, foster relationships, build a recovery network, participate in support groups, and be alert for signs of relapse. Family involvement in professional treatment and support groups is essential so that families can help the ill member and obtain help for themselves. The psychoeducational family treatment model provides an excellent approach that can be adapted for use in this particular dual diagnosis.

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Chapter 10 Organic Mental Disorders and Chemical Dependency An Overview Many studies have suggested that chronic alcoholism is associated with dementia in later life. The ECA survey discussed in previous chapters found that among persons fifty-five years of age or older, the prevalence of alcohol abuse and dependency is about 1.5 times greater among those with mild and severe cognitive impairment than among persons with no cognitive impairment. 1 Clients with organic disorders may been seen in any chemical dependency or psychiatric treatment setting. Geriatric clients are more likely to be seen initially in a psychiatric hospital or mental health outpatient clinic. Chronic alcoholics with brain diseases may be seen in community-based social detoxification programs, halfway houses, or other long-term residential programs. Organic Disorders Organic disorders are those involving structural damage to the brain. Organic mental syndrome (OMS) refers to conditions in which the etiology is unknown, while organic mental disorder (OMD) refers to conditions in which the etiology is known or presumed, such as alcohol withdrawal delirium.2 (For the sake of simplicity, when referring to both the syndrome and the disorder, we will use the abbreviation OMDS.) Abuse of or dependence on any class of psychoactive substances can produce OMDS, such as alcohol hallucinosis, hallucinogen delusional disorder, cocaine delusional disorder, cannabis delusional disorder, and amphetamine delirium.3

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Features of OMDS There are many specific types of OMDS; consequently, the clinical presentation will vary among clients. Nevertheless, these conditions all involve certain combinations of psychological or behavioral abnormalities, including the following: 4 · Psychotic features: delusions, hallucinations, incoherence, loose associations, illogical thinking, or bizarre, disorganized, or catatonic behavior. Cocaine addicts, for example, sometimes develop persecutory delusions or experience tactile hallucinations of bugs ("cokebugs") crawling in or under their skin. · Anxiety features: irrational and persistent anxiety or panic. For example, hallucinogen abusers may experience marked anxiety or may fear they are losing their mind. ·

Affective features: depressed, irritable, or expansive mood with accompanying cognitive or vegetative features.

· Features usually associated with personality disorders: antisocial, aggressive, violent or oppositional behavior; suspiciousness; emotional lability; impaired impulse control or judgment; or marked apathy and indifference. · Cognitive features: short- and long-term memory disturbance, disturbance of attention and orientation, and impairment in intellectual abilities. Diagnosing OMDS In addition to clinical interviews and mental status examinations, approaches to the diagnosis of OMDS include the following: · Laboratory tests to assess structural and functional state of the brain, the chemistry of its supportive environment, and non-central nervous system biological manifestations of diseases affecting the brain. These tests include complete blood count; blood chemistry screening; serology of syphilis and AIDS; toxicology screening; serum thyroxine, serum folate, and B12; urinalysis; and chest film EKG, EEG, and computed tomography.5 · Psychometric evaluation of mental function to assess spontaneous behaviors and responses to cognitive challenges. Tests available include the Wechsler Adult Intelligence Scale, the Halsted-Reitan Battery or its components, Wechsler Memory Scale, Bender Gestalt, Benton Visual Retention, or the Luria-Nebraska test.6 Brain dysfunctions can be reversible or chronic. Delirium tremens, for example, are a reversible OMD, since mental functioning returns to

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normal once alcohol withdrawal is complete. In contrast, Alzheimer's disease is a chronic disorder; afflicted individuals follow a continuous downhill course. The varieties and causes of these disorders are too numerous to discuss here. We will, however, discuss the two forms of brain failure that are most frequently seen in alcoholics and that are closely associated with chronic abuse of alcohol: amnesias and dementias. These are the OMDS you are most likely to encounter in practice. Amnesias A blackout, which is a period of memory failure caused by alcoholism, is a reversible amnesia. Once alcohol has cleared from the body and the brain has had an opportunity to recover from the chemical injury, memory function returns. The classic irreversible alcohol-related amnesia is called alcohol amnestic disorder (formerly known as Korsakoffs syndrome). As we'll explain, this condition is unusual in that many of those affected with it have learned to compensate for their deficiencies in an unusual manner. For this reason, many counselors may be dealing with clients who have alcohol amnestic disorder, but the counselors may never recognize the presence of the syndrome. Clients with alcohol amnestic disorder have a defect in their ability to learn new information. They may have clear memories of the past and remember nearly all the things they learned years ago, but once the disease process starts, they are unable to acquire much, if any, new information or memories. This selective memory defect for new events is sometimes called an anterograde amnesia. Some of those afflicted with this condition have developed a way of filling in the holes in their memories by is, by creating new memories of events that never happened. Confabulation is very different from lying. Unlike liars, clients who confabulate have complete faith in the accuracy of their false memories, nor is confabulating considered a voluntary behavior pursued in the hopes of achieving some secondary gain. Instead it is a strategy by which the brain compensates for the lost ability to learn new things.confabulatingthat Clients with alcohol amnestic disorder retain most of their other intellectual abilities. They may function well at their jobs or in their homes for many years before the problem is noticed by othersincluding their treat-

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ment counselors. They get by on their old memories and old knowledge without being called upon to learn or do things in a new way. This is especially true if their drinking is tolerated or enabled by family or friends. Deficits are then attributed to intoxication rather than some kind of brain disease. Alcohol amnestic disorder is believed to be caused by a deficiency in the B vitamin thiamine resulting from long bouts of heavy drinking without adequate food intake. Thiamine is necessary for the body to use carbohydrates as fuel. It is also needed to metabolize the calories supplied by alcohol. Due to thiamine deficiency, many tiny pinpoint hemorrhages appear in parts of the brain that control recent memory and the processing of new information. Other areas of the brain are left unaffected. This explains why the disorder appears to spare other aspects of intellectual functioning. Case History: Andrew Andrew is forty-eight years old, married, the father of two children. He was a prominent attorney in his hometown until three years ago, when his partners suggested he take an early retirement. Andrew is currently residing at home and requires a daytime private-duty nurse. He began drinking heavily in social situations while in law school. By the time he was thirty, he was binge-drinking once or twice a month. His binges lasted three or four days, after which his wife would help sober him up, feed him, and clean him so he could go to the office. At the age of thirty-nine, he was cited three times for driving his car while under the influence of alcohol and was forced to participate in a two-week alcohol education program. During the last session, the instructor handed out a test on the material that had been presented. Andrew scored very poorly on the test and had to repeat it three times before he passed. Andrew had always been scholastically successful, graduating cum laude from college, and making the law review. His difficulty with the examination confirmed his wife's feelings that somehow he had changed. He dismissed the problem, attributing his poor test performance to "lousy teaching" and boring classes. Although he was attending alcohol education classes, Andrew continued to binge-drink. Three years later, at a business dinner for a new client, Andrew embarrassed his partner by repeatedly calling the client by the wrong name. He told the partner that he and the client were good friends and neighbors, when in fact they hadn't met until that evening. The partner assumed Andrew had been drinking too much again.

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Andrew continued to be somewhat productive at work. Although he tended to misidentify people and places, little was made of it. He made errors around the house, such as forgetting where he put things, but no one suspected a major problem. His binge drinking continued, and his family became accustomed to his extended periods of drinking and not eating. The law firm continued to expand and grow. The old offices couldn't accommodate new staff, so the firm moved to new and larger facilities on the other side of town. Andrew did poorly in finding his way to the new office. In fact, on the firm's first day at the new facility, he went to the old vacated offices. He was embarrassed about not being able to find the new office and decided to call in sick. The second day, he called a colleague and suggested they carpool to work. Andrew started going to work only on the days his colleague could drive him. Once in the office, he was even less effective. He was unable to find his way from one part of the building to another. He couldn't find his new office, nor did he recognize his new secretary. Yet he seemed to be his usual self. His performance declined markedly in the new office. Although he gave elaborate explanations for his apparent forgetfulness, his co-workers noticed a serious decline in the quality of his work. His partners kept asking him to see a doctor for a checkup, but Andrew refused. He seemed to work the best with the old clients but had major difficulties with the new ones. Colleagues found they had to repeat instructions and whole conversations with him again and again. Eventually, Andrew was sent to a doctor who immediately recognized a memory problem. After evaluations by a neurologist and a psychologist who both diagnosed alcohol amnestic disorder, it was decided he could no longer function in the workplace. His partners suggested an early retirement, and Andrew remained in the familiar surroundings of his home. With time, he became increasingly apathetic. He even lost interest in drinking. Assessment Criteria According to DSM-III-R* criteria, an alcohol amnestic disorder is present when there is an amnestic syndrome (both short-term and long-term memory impairment, not due to delirium or intoxication) that follows the *Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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prolonged, heavy ingestion of alcohol and that is not due to any other physical or mental disorder. 7 The Dementias Dementias represent a cluster of various forms of brain failure. Generally, dementia combines the memory impairment seen in amnesias with more global intellectual deficits. Affected people have problems with orientation to person, place, or time. Dementia affects such functions as vocabulary and arithmetic skills, abstract thinking, problem solving, and the ability to shift from one concept to another. Memory for recent and remote events and the ability to recognize familiar people and places are impaired. Judgment and insight into one's own behavior are also diminished. There are many causes of dementia, including poor nutrition, head trauma, Alzheimer's disease, thyroid problems, and the effects of drugs. Some types of dementia may be reversed with medication or neurosurgery; other types may result in a progressive decline in functioning and self-care. There is some debate about the existence of a type of dementia that results directly from alcoholism rather than from poor nutrition, head injury while drunk, or Alzheimer's disease.8 Another form of brain disorder is alcoholic dementia, or so-called wet brain, in which CT scans or autopsies of alcoholics' brains reveal a slight smoothing of the usual crevices and fissures. The normal passageways for spinal fluid in the brain, called ventricles, are frequently dilated to twice their normal size, while the actual weight of the brain is decreased. Brains from alcoholics with dementia show marked loss of brain tissue and replacement of brain mass by spinal fluid. Unfortunately, alcoholic dementia is an irreversible condition, usually with a progressive downhill course. Families may find it increasingly difficult to care for such people at home. Self-care and personal hygiene are so impaired that skilled nursing is ultimately required. Clients with this disorder may develop personality changes and mood disturbances that further complicate their care. It is common for people with alcoholic dementia to spend their last years in a custodial institution. Assessment Criteria The DSM-III-R* criteria for dementia include the following:9 *Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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1. There is evidence of impairment in short- and long-term memory. 2. At least one of the following appears: ·

impairment in abstract thinking

·

impaired judgment

·

other disturbances of brain functioning (e.g., aphasia, apraxia, agnosia)

·

personality change

3. The disturbance significantly interferes with work, social activities, or relationships. 4. There is evidence of a specific organic factor that appears to be etiologically related to the disturbance, or an etiologic organic factor can be presumed. The DSM-III-R criteria for alcoholic dementia (dementia associated with alcoholism) are as follows: 10 1. Dementia occurs, following the prolonged, heavy ingestion of alcohol and persisting at least three weeks after alcohol ingestion stops. 2. There has been exclusion, by history, physical examination, and laboratory tests, of all causes of dementia, other than prolonged, heavy use of alcohol. Assessment Issues In some cases, your only clue to a problem with alcoholic dementia may be that clients get lost each time they come in for an appointment or they repeatedly forget your name or someone else's. All new clients admitted to a chemical dependency or psychiatric treatment program should at some time be given an evaluation of intellectual functioning. A quick and valid screening method that the counselor can easily perform is called the Mini-Mental State Exam. This takes only five or ten minutes to administer, yet it has been shown to be reasonably accurate.11 The Mini-Mental State Exam is performed as follows: Orientation 1. Ask patients to identify the date, year, season, day, and month. Score one point for each correct answer (maximum score: 5). *Diagnostic and Statistical Manual of Mental Disorders, Third EditionRevised [DSM-III-R] (Washington, D.C.: American Psychiatric Association, 1987).

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2. Ask patients to give the name of the hospital or clinic, the floor or building, and the state, county, and town in which the facility is located. Score one point for each correct answer (maximum score: 5). 3. Slowly and clearly name three unrelated objects, such as a red rose, a derby hat, and Main Street, and ask clients to repeat them. Score one point for each object recalled (maximum score: 3). Use this round to determine score, but repeat the test as many as six times until clients can repeat all three objects. Attention and Calculation 4. Ask patients to count backward by sevens, starting at 100. Stop patients after five subtractions (93, 86, 79, 72, 65). Score one point for each correct answer (maximum score: 5). If clients cannot or will not perform this task, ask them to spell the word world backward. Assign a score based on the number of letters given in the correct backward order. (For example, dlrow scores 5 points, dlorw 3.) Recall 5. Ask: ''Do you remember the three words I asked you to remember a few minutes ago? What were they?'' Score one point for each word correctly remembered (maximum score: 3). Language 6. Show clients a wristwatch, then a pencil, and ask them to name the objects. Score one point for each correct answer (maximum score: 2). 7. Ask clients to repeat the following phrase: "No ifs, ands, or buts." Allow only one trial. Score one point if clients repeat the phrase accurately, zero if not. 8. Give clients a blank piece of paper and issue the following command: "Take the paper in your right hand, fold it in half, and put it on the floor." Score one point for each part of the command successfully completed (maximum score: 3). 9. On a blank piece of paper, write the sentence "Close your eyes" large enough to be easily read. Hand the paper to your clients and ask them to follow the directions. Score one point if the clients actually close their eyes. 10. Ask clients to write a sentence on a blank piece of paper. Don't dictate the sentence; it must be spontaneous. Score one point for any response that contains a subject and a verb.

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11. On a clean piece of paper, draw intersecting pentagons with each side being about one inch. Instruct clients to "please copy this figure exactly as it is." All ten angles must be present and two must intersect to score one point. 12. Add up all the points awarded from each task (maximum is 30). Scores of 20 or less indicate that patients have a markedly impaired cognitive state and should have a consultation with a psychologist to further evaluate their intellectual functioning. These individuals may not be suitable for participation in a chemical dependency rehabilitation program due to their learning impairments. Clients with schizophrenia or affective disorders may also score low on this test because of the thinking problems these illnesses produce. Memory disorders may be due to reversible causes. Some physicians may prescribe thiamine tablets to such patients in hopes of stopping the progression of the disease. This approach may or may not be effective. Since any kind of damage to the parts of the brain controlling memory could resemble alcohol amnestic disorder, a full neurologic evaluation, including a CT scan of the brain, is usually needed. Alcoholics appear to be more prone to head injury and are at greater risk for other causes of memory problems such as a subdural hematoma (a blood clot on the brain). Obtain a psychiatric consultation on any client with memory problems or other types of intellectual problems. Head injuries, thyroid problems, drug reactions, infectious diseases, and heart problems are just a few correctable causes of dementia. Consultation should occur in the following order: 1. a psychologist assesses intellectual or memory deficiencies 2. a neurologist evaluates for reversible forms of organic disorders 3. a psychiatrist determines if there is a depressive illness that is producing an apparent yet otherwise unexplained loss of intellectual functioning that can be treated with antidepressants. Counseling Issues It is essential to identify clients with organic brain syndromes. Most of these clients have impaired ability to work or learn effectively in chemical dependency rehabilitation programs and are poor candidates for psychotherapy. However, some of these clients may benefit from memory training or other specialized treatment that helps them make full use of what intellectual capacity remains and helps them achieve sobriety. 12

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Detoxification should take place in a medical setting, since these clients may have other physical complications, such as cardiovascular disease, that may be worsened by the alcohol withdrawal syndrome. Such patients may be uncooperative and disoriented and require additional nursing support. Because disoriented clients tend to wander off, they may need to be restrained in their beds or chairs. Family interventions are extremely valuable, not only to provide information about the disease, its prognosis, and the community resources available to those with organic disorders, but also for psychotherapeutic purposes. Families assume the bulk of responsibility for the care of these afflicted people. It is not unusual for this family burden to trigger intense feelings of anger and guilt. When the person with an organic disorder can no longer be maintained at home or dies, a family crisis can ensue. Therapy can help family members release and discuss their feelings and restore order to a disrupted family environment. Many individuals with dementia eventually require a skilled nursing facility, both to provide care and to restrict access to alcoholic beverages. New treatments may emerge that will stop the progression of these illnesses and restore intellectual functioning so that these clients can benefit from psychotherapeutic and educational interventions. Until that happens, there is little counselors can offer these clients beyond diligent assessment, experimental forms of memory training, and family therapy. Summary A number of organic mental diseases are associated with chemical dependency, especially with chronic alcoholism. The damage done in some forms of organic disorders is reversible; in other forms, however, it is not. Clients with these disorders are seen throughout the continuum of care. In more serious cases, clients need long-term nursing or other custodial care because they are unable to care for themselves.

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Chapter 11 Relapse Prevention and Dual Disorders An Overview Relapse is a significant recovery issue for all clients with dual disorders. Chemical dependency disorders and many major psychiatric conditions are considered chronic, persistent, and relapsing illnesses. Relapse to alcohol and drug abuse can precipitate or exacerbate a psychiatric relapse. The reverse is also true: clients may use alcohol or drugs to relieve psychiatric symptoms, but when they stop this form of self-medication, the psychiatric symptoms reemerge. Impaired judgment associated with certain psychiatric symptoms, such as mania or psychosis, can fuel the use of alcohol or drugs. Outcome studies indicate that most people treated for any type of chemical dependency relapse at least once; a significant number experience two or more relapses. Different studies on individuals with alcohol and drug problems who underwent a variety of treatment interventions show relapse rates ranging from 40 percent to 80 percent or more. 1 By the same token, people with mental illnesses such as schizophrenia or a major affective disorder tend to relapse. Many have chronic or persistent conditions in which some symptoms are experienced more or less continuously. Others may experience two or more discrete psychiatric episodes over time, a condition known as recurrent mental illness. It is estimated that over half of the people who experience an episode of major depression will experience another episode at some time in their lives. About 20 percent to 35 percent of those with recurrent depression will experience chronic illness in which they will continue to be symptomatic and suffer from social impairment.2 Relapse rates appear to be higher among patients with dual disorders

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than among those with only one disorder. Catalano and colleagues conducted a major review of relapse rates in alcoholism and heroin addiction and reported a strong association between psychiatric impairment and relapse in opiate addiction, and some association between psychiatric impairment and relapse in alcoholism. 3 Marlatt and colleagues found that negative emotional states, such as depression, are the main cause of relapse in addicts.4 Studies by McLellan and colleagues indicate that chemically dependent clients with the highest global ratings of psychiatric severity are most vulnerable to alcohol and drug relapse.5 Kofoed and colleagues found high dropout rates among dual diagnosis clients participating in an outpatient program, particularly among those with coexisting personality disorders.6 Our own preliminary data on almost two hundred patients participating in an inpatient dual disorders program showed higher rates of psychiatric hospitalizations among this group than among those admitted with psychiatric disorders only. Factors Associated with Treatment Outcome Factors associated with poor outcome among the chemically dependent and mentally ill include severity of the disorder, lack of social or family supports, and poor social skills.7 It's not surprising, therefore, that skills training programs have been found to have a positive effect on psychiatric and chemically dependent clients.8 Chemical dependency outcome studies are fraught with conceptual and methodological problems that make the findings difficult to interpret. Even so, despite the high relapse rates for chemical dependency, treatment has been shown to be effective for many individuals, especially when measures of improvement take into account psychosocial functioning as well as reductions in substance use. Relapse Precipitants A number of intrapersonal, interpersonal, environmental, and lifestyle factors interact with and contribute to chemical dependency or psychiatric relapse. Seldom is it the case that one factor alone leads to relapse; usually a combination of factors are involved. · Mary reported that she drank alcohol and smoked marijuana because she felt anxious, bored, and depressed. She had very little structure in her day-to-day life and didn't know what to do with her free time. Mary often struggled with negative emotional states and was most vulnerable to using chemicals when feeling down or bored.

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· Tyrone became severely depressed and suicidal after coming down from a cocaine binge. This binge took place shortly after Tyrone stopped taking medication for his bipolar disorder. He experienced a very strong cocaine craving, which he was unprepared to cope with, and felt he was "not having any fun" since he had gone off drugs. He had also grown tired of taking medication for his psychiatric illness. · Lisa had been off drugs for eight months and was stable from her borderline disorder. She was asked out on a date by an ex-boyfriend with whom she used to get high on PCP (angel dust). Lisa had been feeling lonely and rejected, and she thought this date would brighten up her spirits, even though she knew she had to be careful around this man because of his drug use. He pressured her into using PCP, however, and she became psychotic following this single use. Most relapse precipitants fall into one of the following categories: 9 · Affective variables (feelings or mood states)anger, anxiety, boredom, depression, emptiness, guilt, loneliness, joylessness, and positive emotional states. ·

Behavioral variableslackof coping skills, problem-solving skills, or personal competency.

· Cognitive variablescognitivefunctioning, beliefs about one's ability to manage high-risk relapse factors, knowledge and understanding of one's illnesses and its treatment, and decision-making skills. · Environmental variablesavailabilityof substances, social pressure to engage in substance use, lack of a support network, homelessness, and stress associated with major life changes. · Lifestyle factorspersistentproblems or symptoms, lack of structure or regularity in daily life, lack of goals or direction, lack of productive roles, or assumption of major roles following an acute episode of psychiatric illness before stabilizing from the illness. · Personal vulnerabilityBecauseof their biological and psychological makeup, some individuals are more sensitive to stress and ordinary life experiences than others. Thus some are sicker than others, their chemical dependency or mental illness more severe, which makes them more prone to relapse or to experiencing persistent symptoms over time. · Physiological variablespost-acutewithdrawal symptoms; cravings for alcohol or other drugs; physical pain and illness; serious medical problems or changes in health status; ingestion of certain medications for a medical,

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dental, or psychiatric problem; or any use of alcohol or other drugs. Even patients who are not chemically dependent can experience a psychiatric relapse if they use alcohol or drugs. · Psychiatric and psychological variablespsychiatric illness or symptoms, psychological problems or issues, other addictive or compulsive disorders, personality traits, poor motivation, and failure to comply with a treatment program. As mentioned before, a psychiatric relapse can trigger a relapse to substance abuse or result from a substance abuse relapse. · Relationship variableslossof a significant relationship, experiencing rejection or severe criticism from a significant other, interpersonal skill deficits, interpersonal conflict, family problems, lack of a social support system, or involvement in a social support system that is a negative influence. · Spiritual variablesexcessiveguilt and shame, lack of meaning or purpose in life, and lack of a belief in the need for help and support from others or a Higher Power. · Treatment-related variablesinappropriate advice or interventions by caregiver or counselor, lack of access to proper professional treatment, being put on a long waiting list for outpatient services following inpatient treatment, failure to respond to early warning signs of relapse, and noncompliance with treatment. Sometimes, a medication used in the treatment of one type of disorder may cause symptoms of another disorder. Antidepressants, for example, can contribute to manic symptoms in some individuals being treated for bipolar disorder. Overview of Relapse-Prevention and Skill-Development Programs Several clinical models of relapse prevention (RP) have been used with a range of addiction and impulse control disorders. 10 Many of the concepts and clinical interventions of these models also apply to individuals with dual disorders. Identifying and coping with high-risk relapse factors, social pressures to use alcohol or drugs, and cravings are clinical issues pertinent to all chemically dependent individuals, regardless of their coexisting psychiatric illnessor even whether they have a second diagnosis. Clinical RP models include, but are not limited to, the following: ·

the cognitive-behavioral model of Marlatt and Gordon11

·

the cognitive-behavioral model of Annis and Davis12

·

the neurological impairment model of Gorski13

·

the addict aftercare model of Zackon and colleagues and McAuliffe and Albert14t Page 185

·

the psychoeducational models of Daley and Wallace15

·

the biopsychosocial model ofChiauzzi16

·

the cognitive-behavioral models of treatment used with sex offenders17

In addition, many different approaches have been used with psychiatric clients that provide information and teach skills helpful in coping with psychiatric disorders and related life problems. Such programs aim to enhance functioning and decrease the chances of future episodes of illness. These include social skills training programs, living skills programs, and coping-with-depression programs, to name just a few. 18 Key Clinical Issues in Relapse Prevention Although treatment models of RP and social skills training have different theoretical bases or areas of clinical focus, they share some common elements. These include providing the client with information and skills to facilitate recovery, promoting interpersonal and intrapersonal change, and reducing the chances of relapse. Many of these programs also help the client prepare to deal with actual episodes of chemical use or exacerbations of psychiatric symptoms. The following sections review RP counseling and education interventions aimed at helping clients with dual disorders. These interventions may be adapted to the individual client regardless of the specific disorders involved. Identifying and Coping with Relapse Risk Factors The first clinical intervention is to help clients identify their relapse risk factors and develop appropriate coping strategies. For the chemically dependent, factors include interpersonal situations (conflict, anger toward another, etc.) and intrapersonal situations (cravings, negative thinking, etc.) that caused the client to drink or use drugs prior to treatment. For psychiatric clients, risks usually involve psychosocial problems that can create stress and exacerbate psychiatric symptoms. Some clients have so many relapse risk factors that addressing each is impossible. In such cases, global approaches such as social skills training, cognitive reframing, assertiveness training, and stress management may be needed to teach skills that can be generalized to address any potential problem situations. These risk factors can be identified in clinical interviews or by using

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inventories and workbooks. The use of such materials gives the client an active role in identifying trouble spots and developing coping strategies. Clinical Aids in Identifying and Coping with Relapse Factors Following is a brief description of some clinical aids that clinicians can use to identify specific relapse risk factors and to develop strategies for addressing them. All of these aids are interactive, requiring active participation on the part of the client. · The Anxiety and Phobia Workbook (Bourne). This comprehensive workbook describes specific skills that are helpful in overcoming problems with panic, anxiety, and phobias, and it provides step-by-step procedures and exercises for mastering these skills. The guide takes a holistic approach to recovery and covers relaxation, exercise, imagery desensitization and real-life desensitization, self-talk, visualization, assertiveness, nutrition, medications, and spirituality. 19 · Coping with Depression Course Participant Workbook (Brown and Lewinsohn). This companion workbook to the Coping with Depression Course takes a social-learning approach to depression. It covers the following areas: relaxation, pleasant activities, constructive thinking, assertiveness, and developing a life plan. The focus of this course is on using problem solving to identify and make specific changes.20 · The Feeling Good Handbook (Burns). This comprehensive handbook focuses on ways to diagnose, monitor, and change moods. Anxiety, depression, fears, and phobias are covered in great detail. Numerous cognitive and behavioral strategies are reviewed to help the reader cope with mood and related problems such as cognitive distortions. Checklists, worksheets, logs, and other interactive tasks are used throughout the handbook. Interpersonal issues such as communication and relationship issues are explored.21 · Inventory of Drinking Situations (IDS) and Inventory Drug-Taking Situations (IDTS) (Annis). The IDS and IDTS help clients identify situations in which alcohol or drugs were used heavily in the pastsituations that represent high risk for the future. Information from these inventories can be used to help clients develop strategies to cope with their relapse factors.22 · Relapse Prevention Workbook and Adolescent Relapse Prevention Workbook (Daley; Daley and Sproule). Each of these workbooksone for adults and one for adolescentsincludes lists of common high-risk relapse factors. The client can use this material to identify, prioritize, and begin

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planning strategies to cope with potentially dangerous situations. The workbooks can easily be used by clients with dual disorders. 23 · When Symptoms Return (Daley and Roth). This workbook provides an overview of recovery and relapse in psychiatric illness. Written in an interactive style, the book asks readers to identify relapse factors and develop coping strategies. This workbook is applicable to various types of psychiatric illness and is well suited for use with the persistently and chronically mentally ill.24 · Staying Sober Workbook (Gorski). This is one of a number of clinical aids developed by this author for use with chemically dependent clients. It consists of many structured journal exercises that guide the client through the nine steps of relapse-prevention planning. Several sections focus on getting the client to make a list of risky situations and develop coping strategies for them.25 · Substance Abuse Problem Checklist (SAPC) (Carroll). The SAPC contains a list of 377 statements that help the client identify specific problems and symptoms that may represent relapse risk factors. Categories include motivation, health, personality, interpersonal and family relationship, job, activities, spirituality, and legal issues.26 · Social and Independent Living Skills (Liberman). This workbook aims to help individuals with psychotic and other chronic forms of mental illness enhance the quality of their lives. It focuses on helping clients develop their ability to identify and manage the warning signs of relapse, to cope with persistent symptoms of mental illness, and to avoid the use of alcohol and street drugs. The last two areas represent common potential high-risk psychiatric relapse factors for individuals with chronic forms of mental illness.27 · Other workbooks. Some of these include Chiauzzi and Liljegren's RP workbook for young people; Washton's workbooks for cocaine addicts; Earley's workbook for cocaine addicts; Matson's workbook for female addicts; and Brownell's workbook for weight control.28 While each manual focuses on a specific population or type of addictive disorder, all address the importance of actively involving clients in identifying potential problems that could contribute to relapse, in developing coping strategies, and in preparing to handle relapse should it occur. Identifying and Coping with Warning Signs of Relapse Another clinical intervention is helping clients learn to identify and

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cope with relapse warning signs. There are many such signs, and they usually appear as changes in clients' attitudes, emotions, thoughts, and feelings. Some warning signs are generic and apply to a variety of disorders. For example, a common behavioral warning sign of relapse to chemical dependency, schizophrenia, or bipolar illness is the patient's cutting back on therapy, missing sessions, or stopping them altogether. In cases of chemical dependence, the warning sign may be the patient's cutting down or stopping participation in a Twelve Step program. Other warning signs are more specific to the disorder. For patients with bipolar disorder, the signs are an irritable or elevated mood, racing thoughts, or thoughts that they were more interesting while experiencing mania. Warning signs in schizophrenia may first emerge as depression, sleep disturbance, and decreased appetite; these may be followed by the emergence or exacerbation of psychotic symptoms such as hearing voices or experiencing paranoid ideation. Relapse warning signs for an alcoholic or cocaine addict may include an increase in thoughts about using substances in a "controlled" way ("just one drink") or very strong cravings to get high. Following are four sets of examples of the more common relapse warning signs. 29 Some of these warning signs are more relevant to a specific disorder, while other warning signs may apply to a variety of disorders. The severity of the warning sign may vary as well. Changes in thinking or thought processes ·

Thinking that treatment is no longer needed or is a waste of time

·

Thinking that treatment (or recovery) is boring or a drag

·

Having critical thoughts of the doctor, therapist, counselor, or self-help group

·

Having negative, pessimistic, or discouraging thoughts about the future

·

Having trouble making decisions

·

Entertaining thoughts of hurting or killing oneself or another person

·

Having racing or disorganized thoughts

·

Being preoccupied with an idea or having obsessive thoughts

·

Experiencing symptoms of thought disorders such as hallucinations or delusions

·

Having trouble concentrating or remembering things

·

Having bothersome thoughts that the person can't get rid of

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Changes in mood or feeling ·

Becoming increasingly sad, moody, or depressed

·

Feeling too excited, high, euphoric, or on top of the world

·

Shifting rapidly from feeling depressed to feeling euphoric

·

Feeling anxious, tense, nervous, agitated, or on edge

·

Feeling fearful

·

Experiencing intense anger, resentment, or hostility

·

Feeling bored

·

Feeling lonely

·

Feeling rejected or believing that others don't care about him or her

·

Feeling guilty, worthless, or hopeless

·

Feeling empty, as if nothing matters

Changes in health habits or daily routine ·

Experiencing deterioration in personal hygiene or appearance

·

Having difficulty falling or staying asleep

·

Sleeping excessively

·

Eating too much or too little

·

Experiencing a significant increase or decrease in energy level

·

Experiencing a significant change in daily routines

·

Experiencing a loss of daily structure

·

Having frequent aches or pains

·

Experiencing a significant increase in somatic symptoms or complaints

Changes in behaviors ·

Talking a lot more or less than usual

·

Isolating or withdrawing from friends or family

·

Acting impulsively without first thinking of the consequences

·

Hurting oneself or another person

·

Getting into arguments or fights with family, friends, or others

·

Cutting down on or stopping medication

·

Cutting down on or stopping counseling or treatment sessions

·

Cutting down on or stopping attendance of self-help support group meetings

·

Cutting down on or stopping attendance of important social, recre-

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ational, sports, school, or church activities ·

Cutting down on or stopping regular contact with a sponsor or other support persons

·

Acting or dressing in strange or bizarre ways

Some warning signs are very obvious to others or to the individual with the disorder, but other warning signs can be subtle, covert, or very idiosyncratic. For example, one drug addict identified ''becoming dishonest'' as a warning sign. He frequently became dishonest several weeks before actually using drugs: lying to his wife, stealing money at work. Eventually he began creating lies to explain why he missed NA meetings and why he was avoiding his NA sponsor. When this pattern developed, it was a matter of days before he began using drugs again. In another instance, a woman with bipolar illness and alcoholism dressed and acted more seductively when first becoming manic. She would set up dates with several different men during the same week and spend inordinate amounts of time on the telephone. If a client has a prior history of psychiatric or chemical dependency relapse, the clinician can identify warning signs by reviewing previous relapse experiences. The client's family should be involved in this process, if possible. For clients in treatment for the first time, the clinician can review lists of common warning signs as well as those specific to the disorders of the client. This will help the client be aware of potential warning signs and prepare to cope with them should they occur in the future. Clinical Aids in Identifying and Coping With Warning Signs of Relapse Several of the clinical aids described in the previous section can help the clinician assist clients in identifying and managing relapse warning signs. The following workbooks offer specific sections on relapse warning signs: ·

Relapse Prevention Workbooks for Chemical Dependency (Daley; Daley and Sproule) 30

·

Relapse and Psychiatric Illness Workbook (Daley and Roth)31

·

Staying Sober Workbook (Gorski)32

·

Symptom Management Module Patient Workbook (Liberman)33

Building a Social Support Network An important RP intervention is to help clients improve their existing support system or build new ones. Doing so improves their chances of getting

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their interpersonal, emotional, social, recreational, creative, and spiritual needs met. The counselor can help the client identify specific people, groups, and organizations that could make up the social support system. This task is relatively easy; the harder job is actually figuring out how to ask for help. Some clients will need help in learning communication skills so they can be better prepared to seek the support of others. Work with clients ahead of time to rehearse their approaches and the things they'll say. Rehearsal will help clients recognize beliefs or interpersonal deficits that they may need to change before they will be comfortable reaching out. Some clients believe that asking for help or support is a sign of weakness or an imposition on other people. We have had clients who felt a great deal of guilt, shame, and embarrassment concerning this issue. Use cognitive strategies to examine and change these belief systems. Clients who have supportive family and social support systems are more likely to experience a better recovery than those who do not. Family members or others closely involved in a client's life may be able to spot warning signs before relapse occurs. If relapse does set in, members of the support system can see that the client gets help. Sometimes, when suicidality or other life-threatening behavior is involved, the family or a friend may have to initiate a psychiatric commitment. It isn't unusual, for example, for some individuals who are manic, psychotic, or suicidal to deny they need help or to resist efforts to help. The only successful intervention in such cases may be a psychiatric commitment. Counselors can provide support and guidance to the family or significant others at these critical times. A social support system also provides a context in which clients can share mutual interests and goals. A client may not only "get" from others but also "give" to them as well. With a network in place, clients' needs for intimacy, closeness, and connectedness with others are more likely to get met, contributing to a greater overall sense of satisfaction. Such a network can include people involved in a client's professional treatment, including the doctor, therapist, or counselor, as well as sponsors or friends from self-help programs. The social support system should include significant others such as family members, roommates, friends, or neighbors. Organizations such as churches, sports teams, and community groups are other important examples of support. In some instances, the behaviors of the client may have caused considerable stress to family or close friends. In such cases, the counselor should help the client consider if "amends" need to be made and when and how to make them.

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Dealing with Social Pressures to Use Chemicals The second most common relapse precipitant among the chemically dependent is social pressure to drink or use drugs. Counselors can help dualdisordered clients identify and anticipate these pressures. Steps for doing so involve listing the events, activities, and situations in which there may be pressure to use, as well as the specific people who may try to tempt the client. Work with clients to show them the potential effects of such pressures on their thoughts, feelings, and behaviors and to develop and implement coping strategies. We have found that it helps when the client can practice several different ways of saying no to offers to use. The most common approaches for coping with social pressures to use alcohol or other drugs are ·

Avoiding high-risk situations in which social pressure will be strong or in which the client feels especially vulnerable.

·

Developing and practicing refusal skills.

· Learning to challenge faulty beliefs, such as "I can't have fun unless I use alcohol or drugs with these people; they won't accept me if I don't use with them." · Practicing behavioral strategies, such as leaving high-risk situations when the pressure is on or creating a list of activities that serve as alternatives to using drugs. Some of the more persistently and chronically mentally ill people who are too disabled to work and therefore receive money from Social Security or public assistance are likely to be pressured on the days those checks arrive by other addicts who know how to manipulate and take advantage of them. Prepare clients for this by discussing ways to avoid these panhandlers or refuse their requests. One technique is to help clients structure their activities on "payday" so they won't cross paths with the offenders. Dealing with Pressures to Stop Taking Psychiatric Medications As we have said, many dual-disordered clients need medications for a psychiatric disorder. Individuals in self-help groups may pressure them to stop taking the medications, unaware that doing so poses a high risk of relapse for the clients. Ask clients to anticipate such situations and rehearse their response. Coping with Cravings Although cravings are common and may be experienced at any point in

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recovery, they typically are more frequent and intense in the first several weeks or months of recovery. Practical counseling interventions include helping clients to ·

understand the nature of cravings

·

anticipate and label cravings

·

rate the intensity of their cravings

·

monitor cravings and the context in which they occur

·

develop strategies to cope with cravings

Even if clients have been chemically free for several months, you should routinely inquire about their desire to drink or use drugs between treatment sessions. A helpful intervention is teaching clients to identify "cues," or precipitants, of alcohol or drug cravings. They must be able to label the craving when it arises. Craving precipitants usually fall into one of two categories: 1people, places, events, experiences, or objects associated with using. Common examples include drinking or drug-use partners; the sight or smell of alcohol or drugs; or seeing, hearing, or smelling things associated with using (needles, mirrors, pipes, papers, white powder, music, etc.).. External precipitants: 2. Internal precipitants: thoughts, feelings, or sensations. Common examples include feeling restless or having thoughts about "missing the action." A "craving log" or journal helps clients keep track of cravings as well as the context in which they occur. Here are the things included in a craving log: 1. date and time of craving 2. intensity on a scale of I (very mild) to 10 (extremely strong) 3. situation in which craving occurred 4. thoughts and feelings experienced after the craving 5. coping strategies used Cravings may be overt (plainly obvious) or covert (the client is not aware of them). In inpatient settings, a craving may appear as irritability, restlessness, a request to be discharged early or against medical advice, or an elaborate excuse for needing a pass to leave the facility. Clients can be taught to rate the intensity of each craving, since intensity dictates the type of intervention that may be needed. In addition, the counselor should discuss the effects of cravings on the clients' thoughts,

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feelings, and behaviors. The counselor can teach clients various coping strategies for managing cravings. These include talking about the craving with supportive others, going to AA or NA meetings, talking oneself through the craving, using other self-talk measures to talk oneself out of giving in to the craving, getting involved in an activity, writing in a journal or craving log, reading recovery literature, praying, asking for help from a Higher Power, or simply accepting that the craving will pass and doesn't have to be acted on. Since cravings may represent a conditioned response to a stimulus, cue exposure can be used in some cases to decrease the intensity of the craving and extinguish it. 34 In this technique, clients are exposed to specific items associated with drug use, such as pipes, needles, powder, alcohol, and so on. Over time, clients learn to control their reflexive responses to such items. Using an Inventory or Symptom Review Daily and weekly inventories are commonly used in recovery. Teach clients to set goals regularly and to review the day or the week to determine if relapse warning signs or high-risk factors were present. This information can then be used to determine if any actions are needed on the part of clients to cope with these signs or risk factors. Such reviews also help clients see progress toward goals and feel a sense of accomplishment. Some ways of using a daily inventory are more structured than others. For example, clients could be asked to take a few minutes at the beginning and end of each day to reflect on recovery, evaluate progress, and identify potential problems. You can also instruct clients to write answers to specific questions at the end of the day, such as "Were there any clues present today indicating that you are building up to alcohol or drug use?" or "Did you experience any high-risk situations today which could trigger a relapse?"35 Another approach is to ask clients to complete a daily planning guide that sets down goals, recovery tasks, and a time plan.36 An evening review inventory, helps clients review progress, problems, and relapse warning signs.37 These tasks could easily be adapted for dealing with recovery from the psychiatric illness as well as the chemical dependency. Several recovery manuals are available to help clients use self-inventories. In the Coping with Depression participant workbook, Brown and Lewinsohn instruct clients to complete a number of different daily inventories: mood ratings, relaxation techniques used, and a tally of positive and negative thoughts.38 Clients are also taught to complete daily forms in

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which they describe upsetting events, beliefs, or self-talk; emotional consequences; and ways to challenge and change their self-talk. Clients also are instructed to complete a weekly plan to help them increase the number of pleasant activities they engage in each day. In the Social and Independent Living Skills: Symptom Management Module, Liberman instructs clients to complete a persistent-symptoms rating sheet each day to monitor persistent symptoms, their severity, and the results of strategies for coping with these symptoms. 39 Clients first identify the persistent symptoms and whether they are mild, moderate, or severe manifestations. They also jot down the coping techniques they used to address each symptom and whether the technique was successful. This strategy, particularly helpful with clients who have such persistent symptoms as hallucinations, delusions, depression, and anxiety, is one of four major skill areas useful in dealing with chronic psychotic disorders. (The other three skill areas are identifying warning signs of relapse, managing these signs, and avoiding alcohol and street drugs.) A daily inventory also helps clients monitor any changes in symptoms that require professional intervention. Building Structure into Daily Life Help clients build structure into their lives by identifying specific goals and steps necessary to reach these goals. Doing so raises clients' selfesteem and provides a feeling of satisfaction and accomplishment. Encourage clients to make daily or weekly activity lists that specify all activities in which they will engage, including ones that bring them pleasure and fun. Many dual diagnosis clients are unemployed because of the disabling nature of their illnesses or because they lost jobs as a result of chemical use or psychiatric impairment. These individuals have a lot of time on their hands and often need practical help to build structure into their daily lives. Helping clients find suitable activities (recovery meetings, volunteering, leisure, etc.) and routines is a protective measure against relapse, reducing boredom and imbuing the client with a sense of direction. Clients also need a reasonable balance between what they "must" do (their obligations) and what they "want" to do (their desires). Balance is also needed between work, play, relationships, and recovery. The more balanced one's lifestyle, the less need there is to use alcohol or drugs to relax, feel good, or escape. Coping with Emergencies Clients must be prepared to take action should relapse occur. A complicating

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factor, however, is that relapse may impair judgment, causing clients to ignore a problem or refuse help from others. The term lapse refers to an initial episode of substance use following a period of abstinence. A lapse does not necessarily lead to a relapse or to a return to substance abuse. Teaching clients to respond to a lapse quickly may very well reduce the likelihood that it will result in a full-blown relapse. Work with clients to identify the steps they can take to get help in the event of relapse. Make sure there is a list of names (therapist, sponsor, friends, etc.) and telephone numbers so that clients can make calls if they are worried about relapsing or if they have relapsed and need immediate help. The counselor can also encourage a client to spell out what he or she wants significant others to do if they notice relapse warning signs or a significant worsening of symptoms, including what they should do if the client refuses to take their advice. 40 Summary A high percentage of people with mental illness or chemical dependency will experience relapse. Rates of relapse are even higher among those with dual disorders, especially those with persistent and chronic psychiatric conditions such as borderline or antisocial personality disorders or recurrent depression. To reduce the risk of relapse and improve outcome, treatment should help clients to recognize the warning signs and risk factors that can lead to a return of symptoms. Strategies for relapse prevention are available, practical, and easy to implement in all treatment settings. Since many people experience multiple episodes of their disorders, clinicians need to teach clients and their families ways to interrupt a relapse in progress and to learn from their successes and failures. Sometimes clients deny or minimize relapse; it may be that the symptoms of their illness have blinded them to the reality of the situation. Clinicians need to be familiar with local commitment procedures in the event that psychiatric hospitalization is needed. This is especially important when clients cannot meet their own basic needs, or if their behavior presents a serious threat to themselves or others.

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Chapter 12 Issues in Dual Disorders Program Development Introduction People with dual disorders, especially the chronically and persistently mentally ill, are at risk of falling between the cracks of treatment systems. They may be shunted back and forth between facilities in their search for appropriate and effective care. When that happens, treatment may be compromised and the outcome unsatisfactory. In recent years, however, treatment providers have become more aware that many clients suffer from multiple disorders. Programs and services for dual-disordered clients and their families have burgeoned in both the chemical dependency and psychiatric environments. Mental health caregivers are receiving more training in dealing with chemical dependency disorders. With the growing awareness that people with dual disorders are best treated within one agency, inpatient, partial, and outpatient psychiatric treatment programs are adding substance abuse specialists to their treatment teams. Similarly, chemical dependency programs are bringing aboard mental health specialists and providing training for staff in dealing with psychiatric disorders. Needs Assessment The programs and services that are offered should reflect the needs of the clients and families served by your hospital, clinic, or treatment agency. Such needs are varied and complex because they involve diagnostic and treatment interventions for chemical dependency as well as psychiatric disorders, and because the psychosocial problems of clients must also be considered. In designing a program, you can address the following issues:

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·

client noncompliance with treatment

·

clients who have trouble integrating into self-help programs such as AA or NA

·

clients whose psychiatric symptoms contribute to chemical dependency relapse

·

clients whose substance use contributes to psychiatric relapse

·

homelessness

·

lack of financial resources

·

limited access to chemical dependency or mental health support groups

·

lack of vocational skills and employment opportunities

·

lack of social support systems

Needs can be assessed formally and informally. One method is to interview clients with dual disorders to discover what their specific concerns or problems are. Family members can be interviewed to learn about the problems a dual diagnosis causes for both the client and family and to determine what resources are needed to solve those problems. Another needs assessment method is to review client records or charts. Doing so provides insight into the prevalence of the dual disorders and the ways the disorders interact to trigger relapse (see chapter 11). Talking with other clinicians and agency personnel is an effective approach. Front-line staff members usually have a pretty good idea of the special problems and needs of clients with dual disorders. To determine where gaps in services exist, your assessment can include a survey of community support groups or programs aimed at people with dual disorders. Some communities have special programs such as SAMI, MISA, CAMI, and Double Trouble, to name just a few. Self-help programs are an essential component of recovery. If such programs for people with dual disorders are not available locally, your plan can include a strategy for creating them. Administrative Support Without the support of administration officials, it is unlikely your program will ever be implemented. Managers need to be shown what the specific problems are and will want to see evidence that educational or clinical programs will indeed make a difference. They will also be concerned about the cost of offering services, including extra staff, training, and supervision. One key issue is whether new services can be integrated into existing programs without overburdening workers.

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Do not assume that just because a need has been identified and a plan to implement service has been created, others will automatically rally to your cause. The concerns of administrators range from the philosophical ("We treat addicts, not the mentally ill") to economic ("Who will pay for these services?") to pragmatic (''Who will provide the services? How do we train the staff?"). For these and other reasons, building on existing programs and using current resources is much more cost-effective than developing totally new programs that require additional staff. Collaboration with Colleagues New programs and services have the best chance of succeeding if you seek the input and support of your co-workers from the outset. Your colleaguesespecially those who have experience dealing with dual-disordered clientscan provide data for the needs assessment and offer valuable suggestions on ways to expand current services and create new programs. This is particularly true if the success of a program depends on getting referrals from other counselors within the hospital, agency, or clinic. Keep in mind that new ideas, no matter how creative, innovative, or useful, are not always welcomed with open arms. Some people may feel threatened by your ideasthey may sense that they will be asked to do more work or that resources will be shunted away from their own programs. You can overcome much of this resistance if you collaborate closely with all those whose work will be affected by your program. Input from Clients and Families Patients and their families are valuable sources of ideas for developing services or programs. In today's treatment environment, consumer inputa form of market researchis an essential aspect of service development and delivery. If you tailor your plan to reflect the needs and desires of those in your community who will be most directly affected by it (and who will directly or indirectly bear its costs), you give yourself a greater chance of success. You also empower clients and families, sending them a message that their insights are valuable and their needs important. Philosophy of the Program A guiding philosophy should underlie any program or service. Dual disorders programs may require a philosophy that is somewhat different from standard approaches. Often, for example, a typical treatment program establishes certain conditions for participating in treatment, such as requir-

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ing that all clients abstain from alcohol or other drugs, comply with medication or counseling recommendations, and attend NA or AA meetings. In contrast, a dual disorders program may regard these not as preconditions for treatment but as treatment goals. Such a philosophy is more realistic and therefore more valuable in dealing with this particular population. Mental health programs sometimes exclude clients with an alcohol or drug problem. At the very least, such programs may make abstinence a requirement for acceptance into the program or clinic. In our view, such a policy is obsolete and potentially dangerous. The fact is that many people suffer from dual disorders. For instance, those with bipolar or schizophrenic disorders who also have chemical dependency are usually best treated in a mental health clinic; such clients should not be denied treatment because of their alcohol or drug problem. Some outpatient chemical dependency programs routinely require clients to attend AA or NA meetings in addition to counseling. This requirement may have to be relaxed for clients (those with schizophrenia, for example) who may not benefit from AA or NA or who feel they don't benefit from it. Chemical dependency programs sometimes exclude clients who are taking medications for a psychiatric illness. These programs may have a misguided belief that use of such medication interferes with recovery, or they may simply lack access to the psychiatric consultants who could evaluate and monitor clients using prescription drugs. Chemical dependency programs looking to expand into the care of those with dual disorders may have to review their policies about use of medications by their clients. Therefore, programs prohibiting the use of psychiatric medications should not attempt to treat more severe cases of psychiatric illness. Program Proposal A written proposal delineating the program or services to be offered is helpful. The proposal should address the following questions: 1. What is the specific clinical population toward whom the program or service will be directed? What are the special needs and problems of this population? 2. What is the treatment philosophy of the program or service? 3. What are the goals of the program or service? If the program is a time-limited and structured group program, what are the goals and objectives of each session?

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4. What types of clinical services will be offeredindividual, group, or family therapy? education and counseling? medications? 5. Who will provide these services, and what qualifications and training do they need? What special training is needed for the current staff who will be involved in providing new services to dual-diagnosed clients? 6. How will clients be assessed for participation in the program? What process and instruments will be used in the clinical evaluation? What are the specific admission criteria? 7. How will clients be oriented to the service or program? What if they refuse to accept treatment even though the caregivers believe the program or service is needed? 8. How long will clients participate in the service or program, and what are the criteria for graduation from treatment? 9. How will special issues or problems be handled, such as relapse, suicidality, or noncompliance? 10. What role will families or significant others play in the treatment? What educational, referral, or advocacy services and programs will be offered to families? 11. What is the role of self-help programs (e.g., AA, NA, Al-Anon, Nar-Anon, support groups for mental illness, and support groups for families of the mentally ill)? 12. How will clients be recruited, oriented, and integrated into the program? 13. How will consumer satisfaction with the services or program be evaluated (i.e., quality assurance or quality improvement activities)? 14. How will the effectiveness of the services be measured and evaluated? Staff Training Before they can feel competent to deal with dual disorders, staff members are likely to need thorough training. Useful methods of training include attending lectures, workshops, and seminars; participating in case discussions; reading; visiting self-help programs; doing group supervision; and observing senior staff members at work with clients. The most important ingredient is hands-on training with clients in individual or group sessions, followed by the opportunity to discuss the process and content of treatment sessions with a more experienced staff member. Counselors need training to develop their sense of self-confidence. Even knowledgeable mental health therapists who must deal with chemi-

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cally dependent clients sometimes feel inadequate because they lack training. Similarly, some chemical dependency therapists feel ill-equipped to face an addicted client who also has a serious mood or thought disorder. Although many counselors are excellent at establishing a therapeutic alliance and providing specific types of interventions, they often believe that their counseling skills do not apply to other treatment populations or that their ''content" knowledge of a particular disorder is insufficient. As a result, many counselors underestimate their abilities and skills. Counselors need to give themselves more credit for what they know about working with clients. Usually, any specific deficits in knowledge about particular diagnoses or the skills needed to help dual-diagnosed clients can be corrected with ongoing training and supervision. Some of the content areas for counselors to know include ·

the causes, symptoms, effects, and treatment approaches for various psychiatric and chemical dependency disorders

·

mental illness and chemical dependency as biopsychosocial illnesses

·

the multi-axial diagnostic system as outlined in the DSM-III-R

·

relationships between mental illness and substance abuse

·

types and effects of substances

·

effect of substance use and abuse on medications prescribed for the treatment of psychiatric disorders

·

effects of substance use and abuse on treatment compliance

·

types of treatment (pharmacologic, psychosocial, community support)

· specific models of therapy (e.g., cognitive, behavioral, interpersonal, dynamic, problem solving, psychoeducation, addiction recovery, relapse-prevention) ·

precipitants of chemical dependency and psychiatric relapse, and relapse-prevention strategies

·

self-help support programs for chemical dependency, mental illness, and dual disorders

·

the continuum of care for psychiatric and chemical dependency disorders

·

community resources (e.g., social services, supportive housing, and vocational)

·

family issues in assessment, treatment, and recovery

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It is helpful for counselors to know how to provide educational and psychoeducational interventions using a combination of teaching, discussion, and interactive approaches. Knowledge of recovery literature and selfhelp resources is imperative. Sample Program 1: Inpatient Dual Disorders Unit Introduction and Brief History Several years ago, to meet the treatment needs of the growing numbers of people with coexisting chemical dependency and psychiatric illnesses, the authors of this book developed a dual disorders treatment program on an inpatient unit. We designed the program to provide services primarily to patients with mood or personality disorders and chemical dependency, whose active psychiatric symptoms necessitated hospitalization. Although we treat a variety of addictions, alcoholism and cocaine addiction are the two most frequent types of chemical dependency that we encounter. At first the program was offered as a specialty program within an existing mood disorders unit. Later it was expanded into a self-contained unit. Because of the diversity of psychosocial problems presented by patients, we have had to be flexible in adapting our services to the population we serve. For example, the typical length of stay in the hospital has decreased because of changes in reimbursement. We have also seen an increase in the number of patients addicted to cocaine and crack. Over time, therefore, we have modified our program to accommodate these developments. Our program treats patients who come to the hospital voluntarily as well as those who are involuntarily committed. Thus there can be a wide range in the degree of the patients' motivation for recovery and in their level of functioning. Our program devotes equal energy to psychiatric as well as chemical dependency recovery issues. It is a highly structured program that places a great deal of importance on the treatment milieu. Detoxification Detoxification services are provided based on the needs of patients. Withdrawal from alcohol dependence is managed by using the Withdrawal Assessment Scale (WAS) and the diazepam-loading dose method. The WAS is an objective rating scale that provides a standardized clinical assessment for alcohol withdrawal. The score from this scale, an index of severity of the withdrawal syndrome, determines the amount and frequency of

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medication needed to attenuate withdrawal symptoms. We usually manage opiate withdrawal by using clonidine hydrochloride; methadone is used when clonidine is contraindicated. Withdrawal from other drugs of abuse is accomplished by gradually tapering the patient off the drug or by substituting a longer-acting medication of the same class of drug. Treatment Services In this program, treatment is provided by a multidisciplinary staff of psychiatrists, nurses, social workers, and specialty counselors, such as creative and expressive art therapists, milieu therapists, chemical dependency counselors, and recreational therapists. Each patient meets daily with the treatment team and individually with various members of the team for assessment and therapy. Family services are provided by social workers and include individual sessions and a weekly multiple-family group. The unit group treatment program is a vital part of care for patients on the dual disorders unit. Each day the patient participates in a variety of group treatments. These groups allow patients to explore common problems and concerns in depth. Issues or problems discussed in group sessions may also be explored in individual treatment sessions. Conversely, issues or problems identified in individual sessions may be explored or worked on in the context of various group sessions. Overall, group programs aim to provide a balance of focus between the psychiatric and the chemical dependency disorders. A specific group may focus mainly on one of these areas, but we constantly emphasize the interrelationship between the disorders. Although each type of group and each group session has a particular format and objectives, the overall goals of the group program are to ·

Provide information on specific topics related to psychiatric illness, alcohol and drug abuse, and recovery from dual disorders.

· Increase patients' self-awareness so that they can relate to the material in a personal way and become aware of specific issues or problems that need to be addressed in treatment. · Help the patient to develop motivation to change and to accept the need for involvement in ongoing professional treatment and self-help programs (e.g., AA, NA, and mental health support groups). ·

Facilitate change in the patient's attitudes and behaviors.

·

Help the patient to develop skills to solve problems and deal with life

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problems. These include cognitive and behavioral skills that the patient can continue to use and build on after discharge. Types and Structure of Groups Both the content and the process are important aspects of the group therapy approach. Content means the "what" of a group: the topics, issues, problems, or skills that are covered. Process is the "how": the way the group is conducted. The more common ways in which problems or issues are explored or skills are taught include open discussion, lectures, behavioral role-plays, monodramas, review of workbook and other written assignments, and the use of creative media. Most groups are interactive, aiming to involve patients actively in the process by encouraging them to share their experiences and problems and to practice new coping strategies. In many cases, the process of helping patients to share their problems and to trust others is in itself therapeutic. Group leaders may give therapeutic assignments during or between sessions. Assignments might include bibliotherapy (directed readings), journals or logs, or workbooks. The average length of a stay in the hospital program is three weeks, and the group program reflects that three-week cycle. Structured psychoeducational and skills groups that cover specific topics are repeated every cycle to allow patients to get the maximum benefit from the program. Groups fall into six categories as follows: 1. Psychotherapy and Expressive Therapy Groups Process groups, held four times a week, are unstructured groups that provide patients an opportunity to discuss their problems, concerns, and feelings. Participants must take responsibility for identifying the intrapersonal and interpersonal issues they want to work on. held twice weekly, use a variety of media to help patients explore issues, feelings, and conflicts. Specific groups frequently focus on an important theme or recovery issue. Such groups are often a safe way for patients to identify and deal with personal issues in a nonverbal way. Creative media also help patients tap unconscious material.Creative and expressive art therapy groups, A psychodrama group, conducted weekly, provides a way for patients to examine interpersonal or intrapersonal issues. Experiential techniques are used to help explore specific issues or concerns identified by patients. Men's and women's groups, held twice a week, provide an opportunity for

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patients to examine issues or concerns in a gender-specific group. A weekly self-evaluation group helps patients take a look at their participation in treatment during the week and evaluate progress toward goals. Patients are required to complete a self-evaluation worksheet prior to attending this group session. 2. Milieu Groups A morning community focus group is a daily, patient-led group that reviews the rules of the program and the treatment activities for the day, assigns tasks to members of the community, and provides them with the opportunity to state their goals for that day. (See Daily Goal Planning and Review Worksheet on page 208-211.) Patients are required to complete a daily goal-planning worksheet to guide them through this process. An evening community focus group is a daily, patient-led group that reviews the events of the day and the progress each patient has made. Patients discuss community concerns and share positive feedback, words of encouragement, or thanks to others during the "raise and praise" segment. A community group, held Friday mornings, is attended by all patients and staff. Issues pertinent to the treatment milieu are addressed. The president of the patient community presents the patient concerns or questions to the staff This is also a chance for staff to raise issues that affect the milieu and to reinforce program policies. A relaxation group teaches techniques for decreasing stress and anxiety. This group, held at the end of each evening, is optional. Gym activities (optional) are scheduled each day to provide fun and a way to release energy and tension. 3. Skills Groups Coping-with-feelings groups, offered twice a week, teach cognitive and behavioral strategies for managing feelings more effectively. Two sessions focus on anger management, two on depression, one on anxiety and worry, and one on guilt and shame. Written materials supplement group sessions. Relapse-prevention groups teach patients to anticipate and cope with the possibility of psychiatric or chemical dependency relapse. Eight groups are offered during the three-week cycle, one each on the following topics: ·

relapse warning signs

·

high-risk relapse factors

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·

craving and impulse control

·

negative thinking

·

refusing alcohol and drug use offers

·

developing a recovery network

·

leisure planning

·

developing an aftercare plan

Workbook assignments help patients relate the material to their situations and develop strategies for preventing or managing relapse. Cognitive therapy groups, offered twice a week to those patients who are likely to benefit from this approach, teach methods for coping with the cognitive distortions and negative thinking that contribute to depression, anxiety, substance abuse, or interpersonal conflict. Specific problems in thinking presented by patients are used to teach the cognitive concepts. Problem-solving groups, held two times a week, teach patients a step-bystep problem-solving process that can be applied to different life problems. Groups focus on specific problems that the patients taking part wish to discuss. A stress management group teaches patients various ways of managing stress without resorting to alcohol or drugs. This group is held weekly. 4. Interactive Educational Groups and Videotapes Educational groups and videos address a range of topics. Each week programs are offered by various team members or guest presenters, such as a pharmacist or nutritionist. 5. AA- and NA-Related Groups Patients need exposure to other individuals who are recovering from similar problems. For this reason, AA and NA are important aspects of recovery from dual disorders. In our program, patients attend weekly AA and NA meetings within our facility and another weekly AA and NA meeting outside the facility. An Al-Anon meeting is also offered to select patients. In addition to self-help meetings, Big Book"discussion groups and other educational groups about recovery are held weekly to introduce patients to recover)y literature and the concepts of the Twelve Step programs. An overview of the Twelve Steps is provided with particular emphasis on Steps One through Three, and on the importance of sponsorship.Alcoholics Anonymous"The

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6. Family Groups Family involvement in treatment is important, both for the patient and for the family. In addition to individual family sessions provided by the social worker, a weekly multiple-family group offers families the chance to learn about dual disorders and recovery, discuss common concerns and problems, and provide mutual support. DAILY GOAL PLANNING AND REVIEW WORKSHEET Name_______________________________ Date _______________________________ 1. Write a brief description of the problem or issue that you want to work on today in treatment. This should relate to the psychiatric and drug/alcohol problems that brought you to the hospital. Be very specific. ________________________________________________________________________ 2. State one or two goals that you would like to achieve in relation to this problem or issue. Be specific. Goal 1: __________________________________________________________________ Goal 2: _________________________________________________________________________ 3. List the steps or actions that you will take to achieve your goal(s). a.________________________________________________________________________ b.________________________________________________________________________

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c.________________________________________________________________________ 4. List one to three potential benefits of reaching your goal(s). a.________________________________________________________________________ b.________________________________________________________________________ c.________________________________________________________________________ DAILY REVIEW OF MY GOAL 1. Did I reach my goal(s) today? ___________ Yes __________ No. Explain your answer. __________________________________________________________________________ WEEKLY SELF-EVALUATION Name ________________________________Date ___________________________ Take some time to think about your involvement in treatment during the past week. Please answer the following questions as best you can. 1. List the specific goals that you set for yourself for this week. Goal 1: _____________________________________________________________________ Goal 2: _____________________________________________________________________ Goal 3: ___________________________________________________________________________

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2. How would you rate your success or failure in reaching these goals? (1 = did nor meet goal; 5 = some progress; 7 = good progress; 10 = met goal) Goal 1 rating =__________ Goal 2 rating =__________ Goal 3 rating =___________ 3. How would you rate your attitude during the past week regarding being in the hospital and working at your recovery? (1 = very negative; 5 = mixed [negative and positive]; 10 = very positive) Your rating =___________ 4. How often during the past week did you feel angry, anxious, bored, or depressed? (1 = never; 3 = seldom; 5 = sometimes; 7 = often; 10 = very often) Angry = __________Anxious = __________Bored = _________Depressed = _________ 5. How often during the past week did you experience a strong craving or desire for alcohol or other drugs? (1 = not at all; 3 = occasionally; 5 = often; 7 = frequently; 10 = constantly) Your rating = ___________ 6. How would you rate your overall participation in treatment during the past week? (I = little participation; 5 = fairly active participation; 10 = very active participation) Your rating = __________ 7. The most difficult or unpleasant task that I had to do this week was . . . ___________________________________________________________________________ (Examples: called a family member or my boss; turned down drugs; asked for help; listened to critical feedback from staff or peers; talked to my children about being in the hospital)

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8. The most significant thing that I did, heard, or learned this week was . . . _______________________________________________________________________ 9. If I were to summarize my week in the hospital and evaluate my participation in treatment, I would say . . . _______________________________________________________________________ Sample Program 2: An Outpatient Program for Individuals with Schizophrenia and Chemical Dependency To meet the treatment and recovery needs of patients with schizophrenia and alcohol or drug use disorders, a number of special programs have been developed for inpatients, outpatients, and day hospital patients. These services supplement already existing interventions such as individual, group, family, or social therapies; psychoeducation; and pharmacotherapy. In addition, patients attend AA meetings and STEMSS meetings. One program offered to outpatients is DARE (Drug and Alcohol Recovery and Education). This is a twelve-session psychoeducational group that meets weekly for an hour and a half. Participants learn how alcohol and drugs have affected them and work toward achieving and maintaining sobriety. Patients are referred to the DARE group by any member of their treatment team. Staff members persuade them to join the program by presenting it as a special program to which they have been invited. A group of patients

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start the program and go through twelve sessions sequentially. New patients are not added during the twelve weeks. DARE uses a psychoeducational approach to teach specific information to patients and to give them an opportunity to relate to the material in a personal way. Handouts are provided, and patients complete structured recovery exercises during group sessions. Creative approaches are used to keep patients interested in the program. One example is the use of ''Jeopardy!'' questions that are printed on index cards. Group members are divided into three teams and given points for identifying questions that go with the answer provided. They are also given reading and homework assignments. Brief pretests and posttests are given at each group session. Topics of the group sessions are as follows: ·

Session 1: Introduction to DARE's purpose and goals; the ground rules; schizophrenia and the brain.

·

Sessions 2-4. Alcohol and drugs and their effects on schizophrenia, medications, and the brain.

·

Session 5: Negative consequences of drug use; making a commitment to change.

·

Session 6: Behavior changeABC model of behavior change; assessing high-risk situations; self-monitoring.

·

Session 7: Behavior change continuedstimulus control; alternative coping responses and rewards.

·

Session 8: Communication and behavioral rehearsal.

·

Session 9: Refusal skills to help deal with social pressures to use alcohol or other drugs.

·

Session 10: Coping with anger, upsets, and daily hassles.

· Sessions 11 and 12: Relapse prevention (warning signs, relapse-prevention contract and plan, and course review); good-byes and awarding of certificates for attending the program.

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Appendix Resources for Clients and Families Daley, D. (1992). Chemical Dependency and Mental Illness: A Resource Guide on Dual Disorders. This book provides a comprehensive listing of professional and self-help literature relevant to chemical dependency, mental illness, and dual disorders. Audiovisual materials helpful in client and family education are described in detail. Information is also provided on publishers of recovery materials, national councils and organizations, self-help programs, government clearinghouses, and university library systems. The Information Exchange (TIE) on Young Adult Chronic Patients, Inc., 20 Squadron Blvd., Suite 400, New York, NY 10956. TIE is an organization that gathers and disseminates information on treating the young adult chronic patient through consultation, publications, conferences, and research. A number of publications and a quarterly bulletin, TIE Lines, provide information on young adults with mental disorders and on treatment programs. Several of TIE's publications focus specifically on dual diagnosis. This organization was started by Dr. Bert Pepper, who has been involved in the area of dual disorders for many years. Self-Help Clearinghouse, Attn: Source Book, St. Clares-Riverside Medical Center, Pocono Rd., Denville, NJ 07834. This book lists hundreds of self-help groups and national toll-free help lines. It also provides guidelines for starting a self-help group.The Self-Help Source Book, The UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation has developed a series of modules that are aimed at helping individuals with psychotic disorders and other chronic forms of mental illness to improve their social and independent living skills. One of these modules is the Symptom Management Module, which aims to enhance the quality of life of patients with disabling psychiatric illness. Many professionals from UCLA and the Brentwood Psychiatric Division at the West Los Angeles Veterans Administration Medical Center were involved in this project. It

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has been field-tested for several years and is based on extensive research. The Symptom Management Module is a structured, educational program that aims to teach chronic patients how to control their mental illness by minimizing the intrusion of symptoms into their daily lives. The four skill areas of this module include ·

Teaching clients to identify warning signs of relapse.

·

Teaching clients to manage warning signs of relapse.

·

Teaching clients to cope with persistent symptoms of mental illness.

·

Teaching clients to avoid alcohol and street drugs.

The module utilizes a variety of learning approaches, including lectures, discussions, role-plays, videotapes, in-vivo exercises, and homework assignments. Included in Social and Independent Living Skills: Symptom Management Module are a user's guide, trainer's manual, patient workbook, and videotapes. Information regarding this module, as well as requests for consultation, can be obtained from Social and Independent Living Skills Program Rehabilitation Medicine Service (B1 17) Brentwood Division West Los Angeles VA Medical Center Wilshire & Sawtelle Boulevards Los Angeles CA 90073 Yoder, B. (1990). The Recovery Resource Book. New York, NY: Fireside. This comprehensive resource book was written for addicts, families, and professionals. It provides narrative information on chemical dependencies, other addictions (love, sex, gambling, money, work, and overeating) and codependence. Interspersed throughout the book are many lists of symptoms, self-assessment questionnaires, fact sheets, excerpts from books, articles, recovery stories, and tips on recovery. It reviews more than 250 books on recovery, as well as recovery magazines; lists nearly five hundred organizations, self-help groups, agencies, and self-help clearinghouses; and provides a guide to publishers of recovery literature.

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Endnotes Chapter 1 Dual Disorders: An Overview 1. K. Scialla, "An Integrated Treatment Approach for Severely Mentally Ill Individuals with Substance Disorders," in ed. K. Minkoff and R. E. Drake (New York: Jossey-Bass Inc., 1991), 69-74.Dual Diagnosis of Major Mental Illness and Substance Disorders, 2. D. Regier et al., "Comorbidity of Mental Disorders with Alcohol and Other Drug Abuse: Results from the Epidemiologic Catchment Area (ECA) Study," Journal of the American Medical Association 264, no. 19 (1990): 2511-2518; J. Helzer and T. Pryzbeck, "The Occurrence of Alcoholism with Other Psychiatric Disorders in the General Population and Its Impact on Treatment," Journal of Studies on Alcohol 49, no. 3(1988): 219-224. 3. Ibid. 4. Ibid. 5. National Institute on Drug Abuse, "Dual Diagnosis: Drug Abuse and Psychiatric Illness," in Drug Abuse and Drug Abuse Research, Third Report to Congress (Rockville, Md.: National Institute on Drug Abuse, 1991), 61-83; J. Goodwin and K. Jamison, Manic Depressive Illness (New York: Oxford University Press, 1990), 210-226: G. Cooper and C. Kent, "Special Needs of Particular Populations: Dual Disorders," in Alcohol and Drug Problems: A Practical Guide for Counselors, B. Howard and I.. Lightfoot, eds. (Toronto: Addiction Research Foundation, 1990); M. Hesselbrock, R. Meyer, and J. Keener, "Psychopathology in Hospitalized Alcoholics," Archives of General Psychiatry 42 (November 1985): 1050-1055; J. Carroll and B. Sobel, ''Integrating Mental Health Personnel Practices into a Therapeutic Community,'' in Therapeutic Communities for Addictions, ed. G. DeLeon and J. Ziegenfugy (Chicago: Charles C. Thomas, 1986), 209-226; B. Rounsaville et al., Evaluating and Treating Depressive Disorders in Opiate Addicts, DHHS Publication No. (ADM) 85-1406 (Rockville, Md.: National Institute on Drug Abuse, 1985); D. O'Connell, ed., Managing the Dually Diagnosed Patient (New York: Haworth Press, 1990); H. Bergman and M. Harris, "Substance Abuse Among Young Chronic Patients," Psychosocial Rehabilitation Journal 9, no. 1 (1985): 49-54; R. Drake and M. Wallach, "Substance Abuse Among the Chronic Mentally Ill," Hospital and Community Psychiatry 40, no. 10 (1989): 1041-1049. 6. Hesselbrock, "Psychopathology." 7. H. Ross, F. Glaser, and T. Germanson, "The Prevalence of Psvchiatric Disorders in Patients with Alcohol and Other Drug Problems," Archives of General Psychiatry 45 (1988): 1023-1081.

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8. N. Albert, Summary of the Research Exchange Meeting of Young Adult Chronic Patients (Rockville, Md.: Alcohol, Drug Abuse, and Mental Health Administration, 1990). 9. D. Daley, I. Salloum, and A. Jones-Barlock, "Integrating a Dual Diagnosis Program in an Acute Care Psychiatric Hospital," Journal of Psychosocial Rehabilitation ( 1991). 10. I. Salloum, H. Moss, and D). Daley, "Substance Abuse and Schizophrenia: Impediments to Optimal Care," 3(1991): 321336.American Journal of Drug and Alcohol Abuse 17, no. 11. G. Layne, "Schizophrenia and Substance Abuse," Journal of Chemical Dependency Treatment 3, no. 2 (1990): 163-182. 12. Goodwin and Jamison, Manic Depressive Illness. 13. Edward Khantzian, "Psychopathology, Psychodynamics, and Alcoholism," in Enyclopedic Handbook of Alcoholism, ed. E. Pattison and E. Kaufman (New York: Gardner Press, 1982), 581-597; M. Bernadt and R. Murray, "Psychiatric Disorder, Drinking, and Alcoholism: What Are the Links?" British Journal of Psychiatry 148 (1986): 393-400; D. Daley., Chemical Dependency and Mental Illness: A Resource Guide for Dual Disorders (Holmes Beach, Fla.: Learning Publications, 1992); B. Stoffelmayr et al., "Substance Abuse Prognosis with an Additional Psychiatric Diagnosis: Understanding the Relationships," Journal of Psychoactive Drugs 21, no. 2 (1989): 145-152; R. Meyer, Addictive Disorders and Psychopathology (New York: Guilford Press, 1986), 3-16. 14. C. Robert Cloninger, "Neurogenetic Adaptive Mechanisms in Alcoholism," Science (1987): 410-416. 15. A. McLellan et al., "Predicting Response to Alcohol and Drug Abuse Treatments," Archives of General Psychiatry 40 (1983): 620-625. 16. R. Catalano et al., "Relapse in the Addictions: Rates, Determinants, and Promising Prevention Strategies," in the 1988 Surgeon General's Report on Health Consequences of Smoking (Washington, D.C.: Office of Smoking and Health, 1988). 17. B. Rounsaville et al., "Prognostic Significance of Psychopathology in Untreated Opiate Addicts," Archives of General Psychiatry 43 (1986): 739-745; B. Rounsaville et al., "Psychopathology as a Predictor of Treatment Outcome in Alcoholics," Archives of General Psychiatry 44 (1987): 505-513. 18. L. Rubinstein, F. Campbell, and D. Daley, "Four Perspectives on Dual Diagnosis: An Overview of Treatment Issues," (1990): 97118.Journal of Chemical Dependency Treatment 3, no. 2 19. V. Johnson, Intervention: How to Help Someone Who Doesn't Want Help (Minneapolis: Johnson Institute, 1989). 20. E. P. Nace, "Alcoholics Anonymous," in ed., ed. J. H. Lowinson, P. Ruiz, and R. B. Millman (Baltimore: Williams and Wilkins, 1992), 486495.Substance Abuse: A Comprehensive Textbook, 2d 21. Adapted from M. Raskin and D. Daley, Treating the Chemically Dependent and Their Families (Newbury Park, Calif.: Sage Publications, 1991), 4-8. 22. Albert, M. Wallen and H. Weiner, "Impediments to Effective Treatment of the Dually Diagnosed Patient," Summary;Journal of Psychoactive Drugs 21, no. 2 (1989): 161-168. 23. Albert, Summary. 24. National Institute on Drug Abuse, "Dual Diagnosis," 25.

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Chapter 2 Chemical Dependency and Recovery 1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3d ed. (Washington, D.C.: APA, 1987), 165. 2. Ibid., 165-186. 3. Ibid., 167-168 4. Ibid., 169. 5. M. Shuckit, S. Zisook, and J. Mortola, "Clinical Implications of DSM III Diagnoses of Alcohol Abuse and Alcohol Dependence," American Journal of Psychiatry 142, no. 12 (1985): 1403-1408. 6. H. Ross, F. Glaser, and T. Germanson, "The Prevalence of Psychiatric Disorders in Clients with Alcohol and Other Drug Problems," Archives of General Psychiatry 45 (1988): 1023-1081. 7. A. McLellan et al., Guide to the Addiction Severity Index, DHHS Publ. No. (ADM) 851419 (Rockville, Md.: National Institute on Drug Abuse, 1985); see also McLellan et al., "New Data from the Addiction Severity Index," The Journal of Nervous and Mental Disease 173, no. 7 (1985): 412-423; McLellan et al., "An Improved Diagnostic Evaluation Instrument for Substance Abuse Clients," The Journal of Nervous and Mental Disease 168, no. 1 (1980): 26-33. 8. J. F. Carroll, Substance Abuse Problem Checklist (Eagleville, Pa.: Eagleville Hospital, 1983); J. Carroll, "The Substance Abuse Problem Checklist-A New Clinical Aid for Drug and/or Alcohol Treatment Dependency," Journal of Substance Abuse Treatment 1 (1984): 31-36. 9. M. L. Seizer, "The Michigan Alcoholism Screening Test: The Quest for a New Diagnostic Instrument," American Journal of Psychiatry 127 (1971): 1653-1658; H. A. Skinner, "The Drug Abuse Screening Test," Addictive Behaviors 7 (1982): 363371; C. MacAndrew, "The Differentiation of Male Alcoholic Outclients from Nonalcoholic Psychiatric Outclients by Means of the MMPI." Quarterly Journal of Studies on Alcohol 26 (1965): 238-246; T. Millon, Millon Clinical Multi-Axial Inventory (Minneapolis: National Computer Systems, 1987); R. 1. Spitzer, J. B. Williams, and M. Gibbon, Instruction Manual for the Structured Clinical Interview for the DSM-III-R (SCID) (New York: Biometrics Research Department, New York State Psychiatric Institute, 1987). 10. G. M. Ellis et al., "Excretion Patterns of Cannabinoid Metabolites After Last Use in a Group of Chronic Users," Clinical Pharmacology and Therapeutics 38 (1985): 572-578. 11. D. Daley, Surviving Addiction (New York: Gardner Press, 1988). 12. Ibid. 13. A. T. Beck and F. Wright, Cognitive Therapy for Cocaine Abuse, unpublished manuscript, 1992; A. Ellis et al., Rational-Emotive Therapy with Alcoholics and Substance Abusers (Elmsford, N.Y.: Pergamon, 1988); E. J. Khantzian, K. S. Halliday, and W. E. McAuliffe, Addiction and the Vulnerable Self: Modified Dynamic Group Therapy for Substance Abusers (New York: Guilford Press, 1990); L. Luborsky, Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive Treatment (New York: Basic Books, 1984); W. E. McAuliffe and J. Albert, Clean Start: An Outpatient Program for Initiating Cocaine Recovery (New York: Guilford Press, 1992); L.. S. Onken and J. D. Blaine, eds. "Psychotherapy and Counseling in the Treatment of Drug Abuse," National Institute on Drug Abuse Monograph Series #104, (Rockville, Md.: U.S. Department of Health and Human Services, 1990); G. A. Marlatt and J. Gordon, eds., Relapse Prevention: Maintenance Strategies in the Treatment of Addictive

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Behaviors (New York: Gulilford Press, 1985); R. A. Rawson, The New Behavioral Treatment Model vols. 1 and 2 (Beverly Hills, Calif.: Matrix Center, 1989); J. H. Lowinson, P. Ruiz, and R. B. Millman, eds., Substance Abuse: A Comprehensive Textbook (Baltimore, Md.: Williams and Wilkins, 1992); G. E. Woody et al., "Psychotherapy for Opiate Addicts: Does It Help?" Archives of General Psychiatry 40(1983): 639-645; G. F. Woody et al., "Psychotherapy for Opiate Dependence," in American Psychiatric Association Handbook on Psychiatric Treatments, ed. H. Kleber (Washington, D.C.: APA Press, 1989). 14. E. Kaufman, "The Psychotherapy of Dually Diagnosed Clients," (1989): 9-18.Journal of Substance Abuse Treatment 6 15. For a discussion of stages of recovery from alcoholism, see the following: S. Brown, Treating the Alcoholic: A Developmental Model of Recovery (New York: John Wiley and Sons, Inc., 1985); M. Miller, T. Gorski, and D. Miller, Learning to Live Again: Guidelines for Recovery from Alcoholism (Independence, Mo.: Independence Press, 1982); S. Zimberg, "Principles of Alcoholism Psychotherapy," in Practical Approaches to Alcoholism Psychotherapy, 2d ed., ed. S. Zimberg, J. Wallace, and S. Blume (New York: Plenum Publishing Corporation, 1985). 16. Alcoholics Anonymous ("The Big Book"), 3d ed. (New York: AA World Services, Inc., 1976); J. F. Carroll, Substance Abuse, D. Daley, Relapse Prevention Workbook for Recovering Alcoholics and Drug Dependent Persons (Holmes Beach, Fla.: Learning Publications, 1986); D. Daley and F. Campbell, Coping with Dual Disorders (Center City, Minn.: Hazelden Educational Materials, 1986); D. Daley, Surviving Addiction (New York: Gardner Press, 1988); D. Daley, Surviving Addiction Workbook (Holmes Beach, Fla.: Learning Publications, 1990); D. Daley, Kicking Addictive Habits Once and for All (Lexington, Mass.: Lexington Press, 1991); D. Daley, Coping with Feelings: A Workbook for Chemical Dependency (Minneapolis: Johnson Institute, 1993); P. Earley, The Cocaine Recovery Book (Newbury Park, Calif.: Sage Publications, 1991); V. Johnson, I'll Quit Tomorrow, 2d ed. (New York: Harper and Row, 1980); G. Kohn, "Toward a Model for Spirituality and Alcoholism," Journal of Religion and Health 23 (1984): 250-259; G. A. Marlatt and J. Gordon, eds., Relapse Prevention: Strategies for the Maintenance of Behavior Change (New York: Guilford Press, 1985); P. Monti et al., Treating Alcohol Dependence (New York: Guilford Press, 1989); Narcotics Anonymous (Basic Text)(Van Nuys, Calif.: NA World Services, Inc., 1983); E. Pattison and E. Kaufman, eds., Encyclopedic Handbook of Alcoholism (New York: Gardner Press, 1982); A. Twerski, Self-Discovery in Recovery (Center City, Minn.: Hazelden Educational Materials, 1987); A. Twerski, Addictive Thinking Center City. Minn.: Hazelden Educational Materials, 1990); J. Wallace, Alcoholism: New Light on the Disease (Newport, R.I.: Edgehill Publications, 1985); A. Washton, Cocaine Addiction, Treatment, Recovery, and Relapse Prevention (New York: Norton and Company, 1989). 17. D. Anderson, The Psychopathology of Denial (Center City, Minn.: Hazelden Educational Materials, 1985). 18. Marlatt and Gordon, Relapse Prevention. 19. A. T. Beck, Cognitive Therapy and the Emotional Disorders (New York: New American Library, 1976); A. Beck, A. Freeman, et al., Cognitive Therapy of Personality Disorders (New York: Guilford Press, 1990); D. Daley, Overcoming Negative Thinking (Minneapolis: Johnson Institute, 1991). 20. Marlatt and Gordon, D. Daley, ed., Relapse Prevention; Relapse: Conceptual, Clinical, and Research Perspectives (New York: Haworth Press, 1990); F. Tims and C. Leukefeld, Relapse and Recovery in Drug Abuse (Rockville, Md.: National Institute on Drug Abuse, 1987).

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21. E. Kurtz, Guilt and Shame: Characteristics of the Dependency Cycle (Center City, Minn.: Hazelden Educational Materials, 1981). 22. National Institute on Drug Abuse, Drug Abuse and Drug Abuse Research, Third Report to Congress (Rockville, Md.: National Institute on Drug Abuse. 1991). 23. Following is a list of research, clinical, and self-help literature related to addiction in the family: A Growing Concern: How to Provide Services for Children from Alcoholic Families, DHHS Pub. No. (ADM) 85-1257 (Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, 1985); R. Ackerman, Children of Alcoholics: A Guidebook for Educators, Therapists, and Parents, 2d ed. (Holmes Beach, Fla.: Learning Publications, Inc., 1983); R. Ackerman and E. Gondolf, "Adult Children of Alcoholics: The Effects of Background and Treatment on ACOA Symptoms," International Journal of the Addictions 26, no. 11 (1991): I 159-1 172; Al-Anon's Twelve Steps and Twelve Traditions (New York: Al-Anon Family Group, Inc., 1981); Alateen: Hope for Children of Alcoholics (New York: Al-Anon Family Group, Inc., 1981); C. Black, It Will Never Happen to Me: Children of Alcoholics-As Youngsters, Adolescents, Adults (Denver: M.A.C., 1982); C. Black, S. Bucky, and S. Wilder Padilla, "The Interpersonal and Emotional Consequences of Being an Adult Child of an Alcoholic," The International Journal of the Addictions 21. no. 2 (1986): 213-231; T. Cermak, Diagnosing and Treating Codependence (Minneapolis: The Johnson Institute, 1988); R. Collins, K. Leonard, and J. Searles, eds., Alcohol and the Family: Research and Clinical Perspectives (New York: Guilford Press, 1990); D. Daley, Family Recovery Workbook (Bradenton, Fla.: Human Services Institute, 1987); D. Daley and J. Sinberg, Taking Care of Yourself When a Loved One Has Dual Disorders (Center City, Minn.: Hazelden Educational Materials, 1989); D. Daley and M. Raskin, eds., Treating the Chemically Dependent and Their Families (Newbury Park, Calif.: Sage Publications, 1991); D. Daley and J. Miller, Taking Control: A Practical Family Guide to Dealing with Chemical Dependency (Holmes Beach, Fla.: Learning Publications, 1993); E. Kaufman and P. Kaufmann, eds., Family Therapy of Drug and Alcohol Abuse (New York: Gardner Press, Inc., 1979); E. Nace, "Therapeutic Approaches to the Alcoholic Marriage," Psychiatric Clinics of North America 5, no. 3 (1983): 543564; R. Pickens and D. Svikis, Alcoholic Family Disorders (Center City, Minn.: Hazelden Educational Materials, 1985); "Special Population Issues," Alcohol and Health Monograph #4(Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, 1982); P. Steinglass, ''Family Systems Approaches to Alcoholism," Journal of Substance Abuse Treatment 2 (1985): 161-167; S. Wegscheider-Cruse, Another Chance: Hope and Health for the Alcoholic Family, 2d ed. (Mountain View, Calif.: Science and Behavior Books, 1991); J. Woititz, Adult Children of Alcoholics, 2d ed. (Deerfield Beach, Fla.: Health Communications, 1990). Chapter 3 Personality Disorders and Chemical Dependency 1. E. Nace, "Substance Abuse and Personality Disorders," Journal of Chemical Dependency Treatment 3, no. 2 (1990): 183-198. 2. Ibid., 188-189. 3. Ibid., 192-193; see also L. Kofoed et al., "Outpatient Treatment of Patients with Substance Abuse and Coexisting Psychiatric Disorders," American Journal of Psychiatry 143, no. 7 (1986): 867-872; E. Nace, J. Saxon, and N. Shore, "Borderline Personality Disorder and Alcoholism Treatment: A One-Year Follow-Up Study," Journal of Studies on Alcohol 47, no. 3 (1986): 196-200; E. Nace, J. Saxon, and N.

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Shore, "A Comparison of Borderline and Nonborderline Alcoholic Patients," Archives of General Psychiatry 40 (1983): 54-56. 4. Nace, "Substance Abuse," 187. 5. J. Carroll, Journal of Chemical Dependency Treatment 3, no. 2 (1990): 240; see also M. Hesselbrock, R. Meyer, and J. Keener, "Psychopathology in Hospitalized Alcoholics," Archives of General Psychiatry 42 (November 1985): 1050-1055; D. A. Regier et al., "Comorbidity of Mental Disorders with Alcohol and Other Drug Abuse: Results from the Epidemiologic Catchment Area (ECA) Study." Journal of the American Medical Association 264, no. 19 (1990): 2511-2518. 6. Personality Disorder: Alternative Aspects, undated handout. 7. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3d ed. (Washington, D.C.: APA, 1987), 335. 8. Ibid. 9. J. Coleman, J. Butcher, and R. Carson, 6th ed. (Glenview, Ill.: Scott, Foresman and Company, 1980), 276.Abnormal Psychology and Modern Life, 10. Theodore Millon, Disorders of Personality (New York: John Wiley and Sons, 1981), 9. 11. A. T. Beck, A. Freeman, et al., Cognitive Therapy of Personality Disorders (New York: Guilford Press, 1990), 41-42. 12. G. Alford and J. Fairbank, "Personality Disorders," in Practice of Inpatient Behavior Therapy, ed. M. Hersen (Orlando, Fla.: Grune & Stratton, 1985), 173-199; Millon, Disorders, 10. 13. Beck et al., Cognitive Therapy, 40-57. 14. Ibid., 46-47. 15. S. B. Blume, "Dual Diagnosis: Psychoactive Substance Dependence and the Personality Disorders," Journal of Psychoactive Drugs 21, no. 2 (1989): 139-149. 16. American Psychiatric Association, 337-342.DSM-III-R, 17. Beck et al., Cognitive Therapy, 47-48. 18. American Psychiatric Association, DSM-III-R, 339-340. 19. Beck et al., Cognitive Therapy, 51-52. 20. American Psychiatric Association, DSM-III-R, 340-431. 21. Ibid., 342-351. 22. Beck et al., Cognitive Therapy, 50-51. 23. American Psychiatric Association, DSM-III-R, 349-350. 24. Beck et al., 49-50.Cognitive Therapy, 25. American Psychiatric Association, DSM-III-R, 351-358. 26. Beck et al., Cognitive Therapy, 43-44. 27. Ibid., 44-45. 28. American Psychiatric Association, DSM-III-R, 354-356. 29. Beck et al., Cognitive Therapy, 45-46. 30. D. Daley and I. Salloun, unpublished data. 31. Beck et al., Cognitive Therapy, 111-212. 32. Ibid., 350-363. Chapter 4 Antisocial Personality Disorder and Chemical Dependency 1. M. Hesselbrock, R. Meyer, and J. Keener, "Psychopathology in Hospitalized Alcoholics," Archives of General Psychiatry 41 (November 1985): 1050-1055; M. Virkkunen, "Alcoholism and Antisocial Personality," Acta Psychiat. Scand. 59 (1979): 493-501; Edward Khantzian, "Psychopathology, Psychodynamics, and Alcoholism,"

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in Encyclopedic Handbook of Alcoholism, ed. E. Pattison and E. Kaufilan (New York: Gardner Press, 1982): 583-584; Richard Rada, "Alcoholism and Sociopathy: Diagnostic and Treatment Implications," in Encyclopedic Handbook, Pattison and Kaufman, eds., 647-654; V. Hesselbrock, M. Hesselbrock, and K. Workman Daniels, "Effect of Major Depression and Antisocial Personality on Alcoholism: Course and Motivational Patterns," Journal of Studies on Alcohol 47, no. 3 (1986): 207-212; R. Cadoret et al., "Alcoholism, and Antisocial Personality," Archives of General Psychiatry 42 (February 1985): 161-167; George Vaillant, ''Natural History of Male Alcoholism V: Is Alcoholism the Cart or the Horse to Sociopathy?" British Journal of Addiction 78 (1983): 317-326; D. A. Regier et al., "Comorbidity of Mental Disorders with Alcohol and Other Drug Abuse," Journal of the American Medical Association 264, no. 19 (1990): 251 1 -2520. 2. C. Robert Cloninger, "Neurogenetic Adaptive Mechanisms in Alcoholism," Science (1987): 410-416. 3. American Psychiatric Association, 3d ed. (Washington, D.C.: APA, 1987), 342-344.Diagnostic and Statistical Manual of Mental Disorders, 4. Theodore Millon, Disorders of Personality (New York: John Wilcy and Sons, Inc., 1981), 199. 5. A. T. Beck, A. Freeman, et al., Cognitive Therapy of Personality Disorders (New York: Guilford Press, 1990), 48-49. 6. Ibid. 7. Ibid., 361. 8. Millon, Disorders, 181-215. 9. American Psychiatric Association, DSM-III-R, 344-346. 10. Our clinical experience has been that clients entering treatment as a result of external pressure, e.g., courts, employer, or family, seem to do comparably to clients who enter treatment voluntarily. Other literature supports this notion. See, for example, J. F. X. Carroll and S. H. Schnoll, "Mixed Drug and Alcohol Populations," in Encyclopedic Handbook of Alcoholism, 744; and J. Laundergan, J. Spicer, and M. Kammeir, Are Court Referrals Effective? (Center City, Minn.: Hazelden Educational Materials, 1979). 11. "Dual Diagnosis: Psychoactive Substance Abuse and the Personality Disorders," (1989): 139-144.Journal of Psychoactive Drugs 21 12. G. E. Woody et al., "Sociopathy and Psychotherapy Outcome," Archives of General Psychiatry 42 (1985): 1081-1086; L. Luborsky et al., "'Therapist Success and Its Determinants," Archives of General Psychiatry 42 (1985): 602-611; L. Gerstley et al., "Ability to Form an Alliance with the Therapist: A Possible Marker of Prognosis for Patients with Antisocial Personality Disorder," American Journal of Psychiatry 146, no. 4 (1989): 508-512. 13. Gerstley et al., "Ability to Form." 14. Millon, Disorders, 213. 15. Beck et al., Cognitive Therapy, 158-159. 16. L. Kofoed et al., "Outpatient Treatment of Patients with Substance Abuse and Coexisting Psychiatric Disorders," American Journal of Psychiatry 143, no. 7 (1986): 867-872. 17. C. A. Haertzen et al., "Psychopathic States Inventory: Development of a Short Test for Measuring Psychopathic States," International Journal of the Addictions 14 (1980): 137-146.

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Chapter 5 Borderline Personality Disorder and Chemical Dependency 1. J. Gunderson, "Borderline Personality Disorder," in Comprehensive Textbook of Psychiatry/V(Baltimore, Md.: Williams & Wilkins, 1989), 1387-1395. 2. L. Kofoed et al., "Outpatient Treatment of Patients with Substance Abuse and Coexisting Psychiatric Disorders," American Journal of Psychiatry 143, no. 7 (1986): 867-872; E. Nace, "Personality Disorders and Substance Abuse," Journal of Chemical Dependency Treatment 3, no. 2 (1990): 187; E. Nace, J. Saxon, and N. Shore, ''Borderline Personality Disorder and Alcoholism Treatment: A One-Year Follow-Up Study," Journal of Studies on Alcohol 47, no. 3 (1986): 196-200; E. Nace, J. Saxon, and N. Shore, "A Comparison of Borderline and Nonborderline Alcoholic Patients," Archives of General Psychiatry 40 (1983): 54-56; D. Inman, L. Bascue, and T. Skoloda, "Identification of Borderline Personality Disorders Among Substance Abuse Inpatients," Journal of Substance Abuse Treatment 2 (1985): 229-232. 3. Paul Soloff, "Borderline Disorders," in Handbook of Outpatient Treatment of Adults, ed. M. E. Thase, B. A. Edelstein, and M. Hersen (New York: Plenum Publishing Corporation, 1990), 309-322. 4. Ibid., 313. 5. Ibid., 313-318. 6. American Psychiatric Association, Dignostic and Statistical Manual of Mental Disorders, 3d ed. (Washington, D.C.: APA, 1987), 346. 7. Ibid., 309. 8. A. T. Beck, A. Freeman, et al., Cognitive Therapy of Personality Disorders (New York: Guilford Press, 1990), 185. 9. J. J. Kreisman and H. Straus, I Hate You: Understanding the Borderline Personality (New York: Avon, 1989), 12. 10. Soloff, "Borderline Disorders," 319. 11. Ibid. 12. Theodore Millon, Disorders of Personality (New York: John Wiley and Sons, Inc., 1981), 349. 13. Beck et al.. Cognitive Therapy, 181. 14. Kreisman and Straus, I Hate You, 7-10. 15. John Gunderson, Borderline Personality Disorders (Washington, D.C.: APA, 1984). 16. Kreisman and Straus, I Hate You, 34. 17. Soloff, "Borderline Disorders," 320. 18. Millon, Disorders, 349. 19. Soloff; Borderline Personality, 321-322. 20. John Gunderson, "Empirical Studies of the Borderline Diagnosis," in Psychiatry: 1982 Annual Review, ed., 1.. Grinspoon, (Washington, D.C.: APA, 1982), 415-436: J. Gunderson, J. Kolb, and V. Austin, "The Diagnostic Interview for Borderline Patients," American Journal of Psychiatry 138, no. 7 (1981): 896-903; J. Perry and G. Klerman, "The Borderline Patient: A Comparative Analysis of Four Sets of Diagnostic Criteria," Archives of General Psychiatry 35 (February 1978): 141-150. 21. A. Loranger and E. Tulis, "Family History of Alcoholism in Borderline Personality Disorder," Archives of General Psychiatry 42 (February 1985): 153-157; J. Gunderson and D. Englund, "Characterizing the Families of Borderlines: A Review of the Literature," Psychiatric Clinics of North America 4, no. 1 (1981): 159-168; J. Guinderson, J. Kerr, and D. Englund, "The Families of Borderlines: A Comparative Study," Archives of General Psychiatry 37 (January 1980): 27-33.

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22. American Psychiatric Association, DSM-III-R, 346-347. 23. For a review of the various treatment approaches to BPD, see the following: J. F. Clarkin, E. Marziali, and H. Munroe-Blum, eds., Borderline Personality Disorder: Clinical and Empirical Perspectives (New York: Guilford Press, 1992); A. T. Beck, A. Freeman, et al., Cognitive Therapy of Personality Disorders (New York: Guilford Press, 1990); 0. F. Kernberg, Severe Personality Disorders (New Haven, Conn.: Yale University Press, 1984); J. F. Masterson, Psychotherapy of the Borderline Adult: A Developmental Approach (New York: Brunner/Mazel, 1976): F. C. B. Gunderson and M. T. Singer, "Defining Borderline Patients: An Overview," American Journal of Psychiatry 199 (1975): 106-115; see also Millon, Disorders, and Soloff, "Borderline Disorders." 24. Soloff, "Borderline Disorders," 323. 25. Nace et al., "Borderline Personality Disorder," 1986, 200. 26. D. J. Buysse, R. S. Nathan, and P. H. Soloff, "Borderline Personality Disorder: Pharmacotherapy," in Handbook of Comparative Treatments for Adult Disorders, ed. A. S. Bellack and M. Hersen (New York: John Wiley and Sons, 1990), 436-458. 27. Soloff, "Borderline Disorders," 327. 28. Ibid., 328. 29. Ibid., 329. Chapter 6 Depression and Chemical Dependency 1. M. Weissman et al., "Affective Disorders," in Psychiatric Disorders in America: The Epidemiologic Catchment Area Study, eds., L. N. Robins and D. A. Regier (New York: The Free Press, 1991), 53-80. 2. M. Schuckit, "Chemical Dependency and Other Psychiatric Disorders," Hospital and Community Psychiatry 34, no. 11 (1983): 1022-1027; D. Goodwin and C. Erickson, eds., Chemical Dependency and Affective Disorders (New York: Spectrum Publications, Inc., 1979); J. F. Maddux, D. P. Desmond, and R. Costello, "Depression in Opioid Users Varies with Substance Use Status," American Journal of Drug and Alcohol Abuse 13, No. 4 (1987): 375-385; W. Dorus et al., ''Symptoms and Diagnosis of Depression in Alcoholics," Alcoholism: Clinical and Experimental Research 11, no. 2 (1987): 150-154. 3. M. Hesselbrock, R. Meyer, and J. Keener, "Psychopathology in Hospitalized Alcoholics," Archives of General Psychiatry 42 (November 1985): 1050-1055. 4. A. R. Bedi and J. A. Halikas, "Alcoholism and Affective Disorder," Alcoholism: Clinical and Experimental Research 9, no. 2 (1985): 134. 5. R. D. Weiss et al., "Psychopathology in Cocaine Abusers," The Journal of Nervous and Mental Disease 176, no. 12 (1988): 719-725; P. K. Kleinman et al., "Psychopathology Among Cocaine Abusers Entering Treatment," The Journal of Nervous and Mental Disease 178, no. 7 (1990): 442-447; B. J. Rounsaville et al., "Psychiatric Diagnosis of Treatment-Seeking Cocaine Abusers," Archives of General Psychiatry 48 (1991): 43-51. 6. K. O'Sullivan et al., "A Comparison of the Chemically Dependent with and Without Coexisting Affective Disorder," British Journal of Psychiatry 143 (1983): 133-138; A. Bedi and J. Halikas, "Alcoholism and Affective Disorder," Alcoholism:. Clinical and Experimental Research 9, no. 2 (1985): 133-134; M. Schuckit, "Alcoholic Clients with Secondary Depression," American Journal of Psychiatry 140, no. 6 (1983): 711-714; M. Schuckit, Drug and Alcohol Abuse: A Clinical Guide to Diagnosis and Treatment,2d ed. (New York: Plenum Publishing Corporation, 1985).

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7. D. Goodwin and K. Jamison, Manic Depressive Illness (New York: Oxford University Press, 1991). 8. D. Behar, C. Winokur, and C. Berg, "Depression in the Abstinent Alcoholic," American Journal of Psychiatry 141, no. 9 (1984): 1105-1107. 9. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3d ed. (Washington, D.C.: APA, 1987), 213. 10. Seventh Special Report to the U.S. Congress on Alcohol and Health (Rockville, Md.: U.S. Department of Health and Human Services, 1990). 11. G. . Keitner, ed., Depression and Families: Impact and Treatment (Washington, D.C..: APA, 1990); J. F. Clarkin, G. I.. Haas, and I. D. Glick, eds., Affective Disorders and the Family: Assessment and Treatment (New York: Guilford Press, 1988); D. C. Daley, K. Bowler, and H. Cahalane, "Approaches to Patient and Family Education with Affective Disorders" Patient Education and Counseling 19 (1992): 163-174; A. B. Hatfield and H. P. Lefley, eds., Families of the Mentally Ill (New York: Guilford Press, 1987). 12. American Psychiatric Association, DSM-III-R, 222-224. 13. K. Merikangas et al., "Familial Transmission of Depression and Chemical Dependency," Archives of General Psychiatry 42 (1985): 367-372; K. Merikangas et al., "Depressives with Secondary Alcoholism: Psychiatric Disorders in Offspring," Journal of Studies on Alcohol, 46, no. 2 (1985): 199-204; D. Goodwin et al., "Psychopathology in Adopted and Nonadopted Daughters of the Chemically Dependent," Archives of General Psychiatry 34 (1977): 1005-1009. 14. A. Beck et al., Cognitive Therapy of Depression (New York: Guilford Press, 1979). 15. E. S. Paykel, ed., Handbook of Affective Disorders, 2d ed. (New York: Guilford Press, 1992); G. L. Klerman et al., Interpersonal Psychotherapy of Depression (New York: Basic Books, 1984). 16. A. Beck et al., Cognitive Therapy of Depression. 17. E. Kurtz, Guilt and Shame: Characteristics of the Dependency Cycle (Center City, Minn.: Hazelden Educational Materials, 1981). 18. For a discussion of anger coping techniques, see R. Novaco, Anger Control: The Development and Evaluation of an Experimental Treatment (Lexington, Mass.: Heath and Co., 1975); D. Burns, Feeling Good: The New Mood Therapy (New York: New American Library, 1980) 135-177; D. Daley, Coping with Anger Workbook (Skokie, Ill.: Gerald T. Rogers Productions, 1991); G. Rosellini and M. Worden, Of Course You re Angry (Center City, Minn.: Hazelden Educational Materials, 1985). 19. A number of books and articles describe in specific detail these treatment approaches. These include A. Beck, Cognitive Therapy and the Emotional Disorders (New York: International Universities Press, 1976); A. Beck et al., Cognitive Therapy of Depression (New York: Guilford Press, 1979); A. Beck and G. Emery, Cognitive Therapy of Substance Abuse (Philadelphia: Center for Cognitive Therapy, 1977); A. Ellis, Humanistic Psychotherapy: The Rational-Emotive Approach (New York: McGraw Hill, 1973); A. Ellis and R. Harper, A New Guide to Rational Living (Englewood Cliffs. N.J.: Prentice-Hall, 1975); D. A. F. Haaga and A. T. Beck, "Cognitive Therapy," in Handbook of Affective Disorders, ed., E. S. Paykel, 511-523, 1992; R. McMullin and T. Giles, Cognitive Behavior Therapy: A Restructuring Approach (New York: Grune and Stratton, 1981); D. Meichenbaum, Cognitive-Behavior Modification: An Integrative Approach (New York: Plenum Publishing Corporation, 1977); T. D'Zurilla and M. Goldfried, "Problem Solving and Behavior Modification," Journal of Abnormal Psychology 78 (1971): 107-126; M. Goldfried and A. Goldfried, "Cognitive Change Methods," in Helping People Change, ed. F. Kanfer and A. Goldstein (New York: Perganmon Press, 1975); D. Burns, Feeling Good: The New Mood Therapy; D. Burns, The Feeling Good Handbook (New York: William Morrow, 1990).

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20. Beck et al., Cognitive Therapy of Depression, 246; see also McMullin and Giles, Cognitive Behavior Therapy,111-112, for a list of fortyfive common ''thoughts that cause problems." 21. Beck et al., ibid. 22. Meichenbaum, 184.Cognitive-Behavior Modification, 23. McMullin and Giles, Cognitive Behavior Therapy, 63-68, 119. 24. D. Burns, Feeling Good, 28-47; see also Beck et al., Cognitive Therapy, 244-271; A. Ellis. 25. Beck et al., Cognitive Therapy, 262. 26. Burns, Feeling Good, 33, 40. 27. Beck et al., Cognitive Therapy, 262. 28. Beck et al., ibid., 120. 29. P. M. Lewinsohn et al., The Coping with Depression Course (Eugene, Ore.: Castalia Publishing Company, 1984); R. A. Brown and P. M. Lewinsohn, Participant Workbook for the Coping with Depression Course (Eugene, Ore.: Castalia Publishing Company, 1984). 30. J. Overall et al., "Persistence of Depression in the Detoxified Alcoholic," Alcoholism: Clinical and Experimental Research 9, no. 4 (1985): 331-333. 31. Beck et al., Cognitive Therapy, 120. 32. G. A. Marlatt, "Lifestyle Modification," in Relapse Prevention, eds., Marlatt and Gordon (New York: Guilford Press, 1985), 280-350. 33. The AA Member-Medications and Other Drugs (New York: AA World Services, Inc., 1984). 34. American Psychiatric Association, DSM-III-R, 232-233. 35. R. C. Fowler, C. L. Rich, and D. Yung, "San Diego Suicide Study: II. Substance Abuse in Young Cases," Archives of General Psychiatry 43 (1986): 962-965. 36. C. L. Rich et al., "San Diego Suicide Study: III. Relationships Between Diagnoses and Stressors," Archives of General Psychiatry 45 (1988): 589-592. 37. National Institute on Alcohol Abuse and Alcoholism, Alcohol and Health: Fourth Special Report to the U.S. Congress (Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, 1982), 84. 38. A. Freedman, H. Kaplan, and B. Sadock, Modern Synopsis of Comprehensive Textbook of Psychiatry (Baltimore: The Williams and Wilkins Co., 1977), 870-874. 39. Ibid., 872-873. 40. The Prediction of Suicide, ed. A. Beck, H. Resnick, and D. Lettieri, (Baltimore, Md.: The Charles Press Publishers, Inc., 1974); see also "Specific Techniques for the Suicidal Patient," in Cognitive Therapy of Depression, A. Beck et al., 209-224. 41. Freedman et al., 872.Modern Synopsis, Chapter 7 Bipolar Disorder and Chemical Dependency 1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3d ed. (Washington, D.C.: APA, 1987), 225-226. 2. Ibid., 216. 3. L. H. Reich, R. K. Davies, and J. M. Himmelhoch, "Excessive Alcohol Use in ManicDepressive Illness" American Journal of Psychiatry 131 (1974): 83-86; D. Goodwin and C. Erickson, eds., Alcoholism and Affective Disorders (New York: Spectrum Publications, Inc., 1979). 4. D. Dunner, B. Hensel, and R. Fieve, "Bipolar Illness: Factors in Drinking Behavior," American Journal of Psychiatry 136 (1979): 583-585. 5. M. Weissman et al., "Affective Disorders," in Psychiatric Disorders in America: The

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L. N. Robins and D. A. Regier, eds. (New York: The Free Press, 1991), 53-80.Epidemiology Catchment Area Study, 6. D. Goodwin and K. Jamison, Manic Depressive Illness (New York: Oxford University Press, 1991). 7. Cf. Goodwin and Jamison, ibid., 214. 8.E. X. Freed, "Alcoholism and Manic-Depressive Disorders. Some Perspectives," Quarterly Journal of Studies of Alcohol 31 (1970): 62-89. 9. T. W. Estroff et al., "Drug Abuse and Bipolar Disorders," International Journal of Psychiatry in Medicine 15, no. 1 (1985): 37-40. 10. S. Mirin, R. Weiss, and J. Michael, "Psychopathology in Substance Abusers: Diagnosis and Treatment," American Journal of Drug and Alcohol Abuse 14, no. 2 (1988): 139157; S. Mirin, R. Weiss, A. Sollogus, and J. Michael, "Affective Illness in Substance Abusers," in Substance Abuse and Psychopathology, S. Mirin, ed. (Washington, D.C.: American Psychiatric Press, 1984), 58-77; S. Mirin and R. Weiss, ''Affective Illness in Substance Abusers," Psychiatric Clinics of North America 9 (1986): 503-514; R. Weiss et al., "Psychopathology in Cocaine Abusers," The Journal of Nervous and Mental Disease 176, no. 12 (1988): 719-725; R. Weiss and S. Mirin, Cocaine (New York: Ballantine Books, 1987). 11. E. V. Nunes, F. M. Quitkin, and D. F. Klein "Psychiatric Diagnosis in Cocaine Abuse," Psychiatry Research 28 (1989): 105-114. 12. Goodwin and Jamison. 224.Manic Depressive Illness, 13. Ibid., 225 14. Ibid., 225. 15. Ibid., 137-167. 16. American Psychiatric Association, DSM-III-R, 217-218. 17. Ibid., 225-226. 18. Goodwin and Jamison, Manic Depressive Illness, 725-745. 19. Ibid., 747. 20. Ibid., 761. 21. D. Daley, Getting Clean: Starting the Recovery Journey (Minneapolis: Johnson Institute, 1993); T. Gorski, Managing Cocaine Cravings (Center City, Minn.: Hazelden Educational Materials, 1991). 22. Goodwin and Jamison, Manic Depressive Illness, 765-766. 23. G. L.. Klerman et al., Interpersonal Psychotherapy of Depression (New York: Basic Books, 1984); J. D. Safran and Z. V. Segal, Interpersonal Process in Cognitive Therapy (New York: Basic Books, 1990); E. S. Paykel, ed., Handbook of Affective Disorders, 2d ed. (New York: Guilford Press, 1992). 24. Goodwin and Jamison, Manic Depressive Illness, 744-745. 25. Ibid., 732. 26. Ibid. 27. Ibid., 735. 28. "Advances in the Treatment of Bipolar Disorder" (Deerfield, Ill.: Discovery International, undated manuscript). 29. Ibid. Chapter 8 Anxiety Disorders and Chemical Dependency 1. W. Eaton, A. Dryman, and M. M. Weissman, "Panic and Phobia," in Psychiatric Disorders in America: The Epidemiologic Catchment Area Study, I.. N. Robins and D. A. Regier, cds. (New York: The Free Press, 1991), 155-179.

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2. M. M. Conger, "Alcoholism: Theory, Problem, and Challenge, II, Reinforcement Theory and the Dynamics of Alcoholism," (1956): 291324.Quarterly Journal of Studies on Alcohol 17 3. T. Stockwell and H. Rankin, "Tension Reduction and the Effects of Prolonged Alcohol Consumption," British Journal of Addiction 77 (1982): 65-74. 4. F. R. Schneier et al., "Alcohol Abuse in Social Phobia," Journal of Anxiety Disorders 3 (1989): 15-23. 5. E. X. Freed, "Alcohol and Mood: An Updated Review," (1978): 173-200.International Journal of Addictions 13 6. C. G. Last et al., "Anxiety Disorders in Children and Their Families," Archives of General Psychiatry 48 (1991): 928-934. 7. J. L. Bibb and D. L. Chambless, "Alcohol Use and Abuse Among Diagnosed Agraphobics," Behavior Research and Therapy 24 (1986): 4958; B. A. Thyer et al., "Alcohol Abuse Among Clinically Anxious Patients," British Journal of Psychiatry 144 (1984): 53-57. 8. M. Hesselbrock, R. Meyer, and J. Keener, "Psychopathology in Hospitalized Alcoholics," Archives of General Psychiatry 42 (November 1985): 1050-1055. 9. Eaton, Dryman, and Weissman, "Panic and Phobia," 155-179. 10. Thyer et al., "Alcohol Abuse," 357-359. 11. D. J. Munjack and H. B. Moss, "Affective Disorder and Alcoholism in Families of Agoraphobics," Archives of General Psychiatry 38 (1981): 869-871. 12. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. 3d ed. (Washington D.C.: APA, 1987), 237-238. 13. Ibid., 238-239. 14. M. M. Weissman et al., "Suicidal Ideation and Suicide Attempts in Panic Disorder and Attacks," New England Journal of Medicine 321 (1989): 1209-1214. 15. E. Bourne, The Anxiety and Phobia Workbook (Oakland, Calif.: New Harbinger Publications, 1990); L. Glanz, Overcoming Anxiety and Worry (Skokie, Ill.: Gerald T. Rogers Productions, 1990); D. Burns, The Feeling Good Handbook (New York: Penguin Books, 1990); D. Barlow and J. Cerny, Psychological Treatment of Panic (New York: Guilford Press, 1988); D. Daley, Coping with Feelings (Minneapolis: Johnson Institute, 1993); R. Peurifoy, Anxiety, Phobias and Panic: Taking Charge and Conquering Fear (Citrus Heights, Calif.: Lifeskills, 1988); L. Michelsohn and L.. M. Ascher, eds., Anxiety and Stress Disorders: Cognitive-Behavioral Assessment and Treatment (New York: Guilford Press, 1987); S. Jeffers, Feel the Fear and Do It Anyway (New York: Ballantine, 1987); G. Clum, Coping with Panic: A Drug-Free Approach to Dealing with Anxiety Attacks (Pacific Grove, Calif.: Brooks/Cole, 1990); M. Gold, The Good News About Panic, Anxiety, and Phobias (New York: Villard Books, 1989); R. Rapee and D. Barlow, Chronic Anxiety: Generalized Anxiety Disorder and Mixed AnxietyDepression (New York: Guilford Press, 1991); A. Beck and G. Emery, Anxieties and Phobias (New York: Basic Books, 1985). 16. Bourne, Anxiety and Phobia Workbook, 66-70; Glanz, Overcoming Anxiety, 11-12; Barlow and Cerny, Psychological Treatment, 99-114. 17. Bourne, 66-67.Anxiety and Phobia Workbook, 18. Burns, Clum, Feeling Good Handbook;Coping with Panic. 19. The references cited in footnote 15 will provide the counselor with excellent information regarding a variety of cognitive interventions helpful for various anxiety disorders; see also A. Beck, York: International University Press, 1976).Cognitive Therapy and the Emotional Disorders (New 20. American Psychiatric Association, DSM-III-R, 241-243.

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21. Ibid., 243-245. 22. M. A. Mullaney and C. J. Trippett, "Alcohol Dependence and Phobias: Clinical Description and Relevance," British Journal of Psychiatry 135 (1979): 565-573; P. Small et al., "Alcohol Dependence and Phobic Anxiety States, I. A Prevalence Study," British Journal of Psychiatry 144 (1984): 53-57. 23. Eaton, Dryman, and Weissman, "Panic and Phobia." 24. K. A. Christie et al., "Epidemiologic Evidence of Early Onset Mental Disorders and Higher Risk of Drug Abuse in Young Adults," American Journal of Psychiatry 15 (1988): 971-975. 25. T. Stockwell et al., "Alcohol Dependence and Phobic Anxiety States, II. A Retrospective Study," British Journal of Psychiatry 144 (1984): 58-63. 26. J. L. Eisen and S. A. Rasmussen, "Coexisting Obsessive Compulsive Disorder and Alcoholism," Journal of Clinical Psychiatry 50 (1989): 96-98. 27. F. S. Sierles et al., "Posttraumaric Stress Disorder and Concurrent Psychiatric Illness: A Preliminary Report," American Journal of Psychiatry 140 (1983): 1177-1179; J. Davidson et al., "A Diagnostic and Family Study of Posttraumatic Stress Disorder," American Journal of Psychiatry 142 (1985): 90-93. 28. B. Boman, "Combat Stress, Posttraumatic Stress Disorder, and Associated Psychiatric Disturbance," American Journal of Psychiatry 142 (1985): 90-93. 29. J. M. Jellinek and T. Williams, "Posttraumatic Stress Disorder and Substance Abuse in Vietnam Combat Veterans: Treatment Problems, Strategies and Recommendations," Journal of Substance Abuse Treatment 1 (1984): 87-97. 30. American Psychiatric Association, DSM-III-R, 247-251. 31. D. H. Barlow et al., "Generalized Anxiety and Generalized Anxiety Disorder: Description and Reconceptualization," American Journal of Psychiatry 143 (1986): 40-44. 32. American Psychiatric Association, DSM-III-R, 251-253. 33. D. A. Bernstein and T. D. Borkovec, "Progressive Relaxation Training: A Helping Manual for Professionals" (Champaign, Ill.: Research Press, 1973). 34. H. L. Williams and 0. H. Rundell, Jr., "Altered Sleep Physiology in Chronic Alcoholics: Reversal with Abstinence," Alcoholism: Clinical and Experimental Research 5 (1981): 318-325. 35. The AA Member-Medications and Other Drugs (New York: AA World Services, Inc. 1984). Chapter 9 Schizophrenia and Chemical Dependency 1. B. J. Rounsaville et al., "Psychopathology as a Predictor of Treatment Outcomes in Alcoholics," Archives of General Psychiatry 44 (1987): 505-513. 2. E. X. Freed, "Alcoholism and Schizophrenia: The Search for Perspectives," Journal of Studies on Alcohol 36 (1975): 853-881; T. A. Bann, "Alcoholism and Schizophrenia: Diagnostic and Therapeutic Considerations," Alcoholism: Clinical and Experimental Research 1(1977): 113117; H. Barry, "Psychiatric Illness of Alcoholics," Substance Abuse in Psychiatric Illness, ed. E. Gottheil, A. T. McLellan, and K. A. Druley (Elmsford, N.Y.: Pergamon, 1980); A. T. McLellan, K. A. Druley, and J. E. Carson, "Evaluation of Substance Abuse Problems in a Psychiatric Hospital," Journal of Clinical Psychiatry 30 (1978): 425-430. 3. S. J. Keith, D. A. Regier, and D.S. Rae, "Schizophrenic Disorders," in Psychiatric Disorders in America: The Epidemiologic Catchment Area Study, L. N. Robins and D. A. Regier, eds. (New York: The Free Press, 1991), 33-52.

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4. Ibid. 5. D. A. Regier et al., "Comorbidity of Mental Disorders with Alcohol and Other Drug Abuses," Journal of the American Medical Association 264 ( 1990): 2511-2518 6. M. Hesselbrock, R. Meyer, and J. Keener, "Psychopathology in Hospitalized Alcoholics," Archives of General Psychiatry 42 (November 1985): 1050-1055. 7. E. J. Khantzian, "The Self-Medication Hypothesis of Addictive Disorders: Focus on Heroin and Cocaine Dependence," American Journal of Psychiatry, 142 (1985): 12591264. 8. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3d ed. (Washington, D.C.: APA, 1987), 187-88. 9. Ibid., 188. 10. Ibid., 188-189. 11. Ibid., 188. 12. Ibid., 189. 13. Ibid., 189-190. 14. Ibid., 190-191. 15. Ibid., 196-197. 16. Ibid., 197. 17. Ibid., 196. 18. Ibid., 198. 19. Ibid. 20. Ibid., 194-196. 21. C. M. Anderson, D. J. Reis, and G. E. Hogarty, Schizophrenia and the Family (New York: Guilford Press, 1986). Chapter 10 Organic Mental Disorders and Chemical Dependency 1. L. K. George et al., "Cognitive Impairment," in Psychiatric Disorders in America: The Epidemiologic Catchment Area Study, ed. L. N. Robins and D. A. Regier (New York: The Free Press 1991), 291-337. 2. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (Washington, D.C.: APA, 1987), 97. 3. Ibid., 131. 4.T. B. Horvath et al., "Organic Mental Syndromes and Disorders," in ed. H. I. Kaplan and B. J. Sadock (Baltimore: Williams and Wilkins, 1989), 599-641.Comprehensive Textbook of Psychiatry/V, 5. Ibid., 603-604. 6. Ibid., 602-603. 7. American Psychiatric Association, DSM-Ill-R, 133. 8. M. S. Goldman, "Cognitive Impairments in Chronic Alcoholics: Some Cause for Optimism," (1983): 1045-1054; R. Tarter and A. Alterman. "Neuropsychological Deficits in Chronic Alcoholics: Etiological Considerations." American Psychologist 38Journal of Studies on Alcohol 45(1984): 1-9. 9. American Psychiatric Association, DSM-III-R, 107. 10. Ibid., 133-134. 11. M. F. Folstein, S. E. Folstein, and P. R. McHugh, "Mini-Mental State: A Practical Method for Grading and Cognitive State of Patients for the Clinician," (1975): 189-198.Journal of Psychiatric Research 12 12. B. S. McCrady and D. E. Smith, "Implications of Cognitive Impairment for the Treatment of Alcoholism," Alcoholism: Clinical and Experimental Research 10 (1 986):

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145-149; G. Goldstein et al., "Three Methods of Memory Training for Severely Amnestic Patients," Behavior Modification 9 (1985): 357374. Chapter 11 Relapse Prevention and Dual Disorders 1. Daley and M. Raskin, "Relapse Prevention and Treatment Effectiveness Studies," in Treating the Chemically Dependent and Their Families, ed. D. Daley and M. Raskin (Newbury Park, Calif.: Sage Publications, 1991), 128-171. 2. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3d ed. (Washington, D.C.: APA, 1987), 229. 3. R. Catalano et al., "Relapse in the Addictions: Rates, Determinants, and Promising Prevention Strategies," in the 1988 Surgeon Generals Report on Health Consequences of Smoking (Washington, D.C.: Office of Smoking and Health, 1988). 4. G. A. Marlatt and J. Gordon, eds., Relapse Prevention: A Self-Control Strategy for the Maintenance of Behavior Change (New York: Guilford Press, 1985). 5. A. McLellan et al., "Predicting Response to Alcohol and Drug Abuse Treatments: Role of Psychiatric Severity," Archives of General Psychiatry 40 (1983): 620-625. 6. L. Kofoed et al., "Outpatient Treatment of Patients with Substance Abuse and Coexisting Psychiatric Disorders," American Journal of Psychiatry 143, no. 7 (1986): 867-872. 7. Daley and Raskin, "Relapse Prevention and Treatment"; Catalano et al., "Relapse in the Addictions"; Marlatt and Gordon, Relapse Prevention. 8. R.P. Liberman, Social and Independent Living Skills: Symptom Management Module (Los Angeles: UCLA Department of Psychiatry, 1988); R. P. Liberman, W. J. DeRisi, and K. T. Mueser, Social Skills Training for Psychiatric Patients (Elmsford, N.Y.: Pergamon, 1989). 9. D. Daley and G. A. Marlatt, "Relapse Prevention: Cognitive and Behavioral Interventions," in Comprehensive Textbook of Psychiatry, 2d ed., ed. J. H. Lowinson, P. Ruiz, and R. B. Millman (Baltimore: Williams and Wilkins, 1992), 533-542; D. Daley and 1.. Roth, When Symptoms Return: A Guide to Relapse in Psychiatric Illness (Holmes Beach, Fla.: Learning Publications, 1992); E. Frank et al., "Three-Year Outcomes for Maintenance Therapies in Recurrent Depression," Archives of General Psychiatry, 47 (1989): 1093-1099; D. W. Heinrichs, B. P. Cohen, and T. Carpenter, "Early Insight and the Management of Schizophrenic Decompensation," Journal of Nervous and Mental Disease 173, no. 3 (1985): 133-138; C. S. Leverich, R. M. Post, and A. S. Rosoff, "Factors Associated with Relapse During Maintenance Treatment of Affective Disorders," International Clinical Psychopharmnacology 5 (1990): 135-156; J. A. Lieberman et al., "Prediction of Relapse in Schizophrenia,'' Archives of General Psychiatry 44 (1987): 597-603; D. J. Miklowitz et al., ''Family Factors and the Course of Bipolar Affective Disorder," Archives of General Psychiatry 45 (1988): 225231; M. E. Thase, "Relapse and Recurrence in Unipolar Major Depression: Short-Term and Long-Term Approaches," Journal of Clinical Psychiatry 51, no. 6 (1990): 51-57; and D. Goodwin and K. Jamison, Manic Depressive Illness (New York: Oxford University Press, 1990). 10. D. Daley, ed., Relapse: Conceptual, Research, and Clinical Perspectives (New York: Haworth, 1989); Marlatt and Gordon, Relapse Prevention; F. Tims and C. Leukefeld, eds., Relapse and Recovery in Drug Abuse (Rockville, Md.: National Institute on Drug Abuse, 1989); R. Laws, ed., Relapse Prevention with Sex Offenders (New York: Guilford Press, 1989). 11. Marlatt and Gordon, Relapse Prevention.

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12. H. M. Annis and C. S. Davis, "Relapse Prevention Training: A Cognitive-BehavioralApproach Based on Self-Efficacy Theory,"in Relapse, Daley, ed., 153-172. 13. T. Gorski, Counseling for Relapse Prevention (Independence, Ill.: Independence Press, 1982). 14. F. Zackon, W. E. McAuliffe, and J. M. Ch'ien, Addict Aftercare: Recovery Training and Self-Help (Rockville, Md.: National Institute on Drug Abuse, 1985); W. E. McAuliffe and J. Albert, Clean Start (New York: Guilford Press, 1992). 15. D. Daley, "A Psychoeducational Approach to Relapse Prevention," no. 2 (1989): 105-124; B. Wallace, "Relapse Prevention in Psychoeducation Groups for Crack Cocaine Smokers," Journal of Chemical Dependency Treatment 2,Journal of Substance Abuse Treatment 6, no. 4 (1989): 229-239. 16. E. J. Chiauzzi, Preventing Relapse in the Addictions: A Biopsychosocial Approach (Elmsford, N.Y.: Pergamon, 1991). 17. Laws, Relapse Prevention with Sex Offenders. 18. Liberman et al., Social and Independent Living Skills; P. M. Lewinsohn et al., Control Your Depression (New York: Prentice Hall, 1986); P. M. Lewinsohn et al., The Coping with Depression Course (Eugene, Ore.: Castalia Publishing Company, 1984). 19. E. J. Bourne, The Anxiety and Phobia Workbook (Oakland Calif.: New Harbinger, 1990). 20. R. A. Brown and P. M. Lewinsohn, Coping with Depression Course Participant Workbook (Eugene, Ore.: Castalia Publishing Company, 1984). 21. D. Burns, The Feeling Good Handbook (New York: Plume, 1990). 22. H. Annis, Inventory of Drinking Situations and Inventory of Drug Taking Situations (Toronto, Canada: Addiction Research Foundation, 1985). 23. D. Daley, Relapse Prevention Workbook: For Recovering Alcoholics and Drug Dependent Persons (Holmes Beach, Fla.: Learning Publications, 1986); D. Daley and C. Sproule, Adolescent Relapse Prevention Workbook (Holmes Beach, Fla.: Learning Publications, 1991). 24. Daley and Roth, When Symptoms Return, 20-28. 25. T. Gorski, The Staying Sober Workbook (Independence, Mo.: Herald House, 1988). 26. J. F. Carroll, The Substance Abuse Problem Checklist (Eagleville, Pa.: Eagleville Hospital, 1983). 27. Liberman, Social and Independent Living Skills. 28. E. Chiauzzi and S. K. Liljegren, Staying Straight: A Relapse Prevention Workbook for Young People (Holmes Beach, Fla.: Learning Publications, 1991); A. Washton, Staying Off Cocaine (Center City, Minn.: Hazelden Educational Materials, 1990): P. H. Earley, The Cocaine Recovery Workbook (Newbury Park, Calif.: Sage Publications, 1991); K. Matson, A Relapse Prevention Workbook for Women (Minneapolis: Johnson Institute, 1992); K. Brownell, The LEARN Program for Weight Control (Philadelphia: Kelly Brownell, 1989). 29. This list of relapse warning signs is adapted from Daley, Relapse Prevention Workbook, and Daley and Roth, When Symptoms Return. 30. Daley, 23, and Daley and Sproule, Relapse Prevention Workbook,Adolescent, 34. 31. Daley and Roth, 33-44.When Symptoms Return, 32. Gorski, 24-99.Staying Sober Workbook, 33. Liberman, 1988, 27-56.Social and Independent Living Skills, 34. D. Daley, Getting Clean: Starting the Recovery Journey (Minneapolis: Johnson Institute, 1993); T. Gorski, Managing Cocaine Cravings (Center City, Minn.: Hazelden Educational Materials, 1991); and A. Washton, Quitting Cocaine (Center City, Minn.: Hazelden Educational Materials, 1990).

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35. Daley, Relapse Prevention Workbook, 22. 36. Gorski, Staying Sober Workbook, 1988, 108. 37. Ibid. 38. Brown and Lewinsohn, Coping with Depression Course. 39. Liberman, Social and Independent Living Skills, 73. 40. Daley and Roth, When Symptoms Return.

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Index A AA Member: Medications and Other Drugs, 150 Addiction Severity Index, 22 Affect, 63-64, 78 Agoraphobia, 128-129, 137-138, 149-150 Alcohol, 25, 109, 127-128, 129 Alcohol amnestic disorder, 173-176 Alcoholic dementia, 176-177 Amnesias, 173-174 assessment criteria, 175-176 case history, 174-175 Amphetamines, 24 Anger, 85-86 Anticonvulsants, 74, 114, 124 Antidepressants, 74, 99-100, 114, 149 Antipsychotics, 114 Antisocial personality disorder, 45-46 assessment criteria, 48-50 assessment issues, 50-51 case history, 47-48 detoxification settings, 52 halfway houses and therapeutic communities, 57 medication and, 58 outpatient programs, 57-58 psychiatric hospitals, 57 rehabilitation programs, 53-57 self-help programs for, 58-59 therapeutic alliance, 51-52 Anxiety disorders, 127-128 generalized anxiety disorder, 145-148 obsessive-compulsive disorder, 138-139 outpatient aftercare, 148-150 panic disorder, 128-136 phobic disorders, 136-138 posttraumatic stress disorder, 139-144 Assessment

of amnesias, 175-176 in antisocial personality disorder, 48-51 in bipolar disorder, 112-114 in borderline personality disorder, 66-68 in chemical dependency, 19-23 in dementias, 176-179 in dysthymia, 100-101 in generalized anxiety disorder, 147-148 in major depression, 81-82 in panic disorder, 131-133 in posttraumatic stress disorder, 141-143 in schizophrenia, 157- 161 Avoidant personality, 42 Awfulizing, 89-90

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B Beck Depression Inventory, 82 Behavior changes, 93-95 Benzodiazepines, 114, 135-136, 149 Bipolar disorder, 107 assessment criteria, 1 12-1 13 assessment issues, 113-114 case history, 110-1 12 characteristics and effects of, 109 counseling issues, 114-122 detoxification in, 122 medication for, 124 outpatient treatment, 123-124 partial hospital and day treatment programs, 123 prevalence of, 108 psychiatric hospitals for, 123 rehabilitation programs and halfway houses for, 122 relationship with chemical dependency, 108-109 self-help programs, 124 Borderline personality disorder affect and, 63-64 assessment criteria, 66-67 assessment issues, 67-68 case history, 65-66 characteristics of, 62 detoxification settings for, 68-69 halfway houses and therapeutic communities for, 72 impulse control and, 63 interpersonal relationships and, 62-63 medication for, 73-74 outpatient treatment for, 73 prevalence of, 61 psychiatric hospital for, 72-73 psychosis and, 65 rehabilitation programs for, 69-72 relationship with other disorders, 62 self-help programs for, 73 self-identity and, 64-65 Breath analyzers, 25

Breathing properly, 134 C Catastrophizing, 90 Character defects, 59 Chemical dependency assessment issues, 21-22 clinical assessment aids, 22-23 diagnostic criteria, 19-21 family involvement in, 33-35 laboratory tests, 23-26 physical recovery from, 28-29 psychiatric illnesses and, 6-8 psychological and behavioral recovery from, 29-31 social and family recovery from, 31-32 spiritual recovery from, 32-33 treatment issues for, 26-28 Cocaine, 24, 77 Cognitive behavioral treatment, 88-93 Confabulating, 173 Consultation, 26 Contingency contracts, 53 Countering, 88 Cravings, 192-194 D DARE, 211-212 Dementias, 176 assessment criteria, 176-177 assessment issues, 177-179 counseling issues, 179-180 Denial, 29 Dependent personality, 42 Depressive disorders assessment criteria, 81-82 case history in, 80-81 characteristics and effects of, 78-79 chemical dependency and, 77-78 counseling issues, 82-96 dysthymia, 100-102 halfway house and outpatient programs for, 97 major depression, 79-100 medications for, 98-100

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prevalence of, 77 psychiatric hospitals for, 96-97 rehabilitation programs for, 96 self-help programs for, 97-98 suicidal risk assessment, 103-104 Dichotomous thinking, 89 Diet, 134 Dual disorders chemical dependency and psychiatric illnesses, 6-8 counselor and, 10-14 defined, 1 family and, 8-10 patient and, 8 prevalence of, 2-8 professional enabling and, 14-15 systems issues in treatment of, 15-16 Dysthymia, 100-102 E Exercise, 134 F Families, 8-10, 22 chemical dependency and, 33-35 resources for, 213-214 schizophrenia and, 167-168 G Generalized anxiety disorder, 145 assessment criteria, 147 assessment issues, 147-148 case history, 145-147 counseling issues, 148 medication for, 148 GGTP, 25 Grief, 86-87 Groups AA- and NA-related, 207 educational and videos, 207 family, 208 milieu, 206

psychotherapy/expressive therapy, 205-206 skills, 206-207 Guilt, 84-85 H Hallucinogenics, 108 Histrionic personality, 41 I Impulse control, 63 L Labeling, 92 Laboratory tests, 23-26, 172 Lapse, 196 Lifestyle changes, 95-96 Lithium, 114-116, 124 LSD, 78 M Mania, 107 Manic-depressive illness. See Bipolar disorder MAO inhibitors, 99, 135-136 Marijuana, 24-25 Michigan Alcohol Screening Test (MAST), 129 Mini-Mental State Exam, 177-179 Mislabeling, 14, 92 Mixed personality disorder, 42 N Narcissistic personality, 41 Narcotics Anonymous, 12-13 National Institute of Mental Health Epidemiologic Catchment Area survey, 3-4, 151, 171 Neuroleptics, 74, 152, 166 Nicotine, 134 O Obsessive-compulsive disorder, 42, 138-139 Organic mental disorders, 171 amnesias, 173-176 dementias, 176-180 diagnosis of, 172-173 features of, 172 Overgeneralizing, 90

P Panic disorder, 128-130, 149 assessment criteria, 131-132 assessment issues, 132-133

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case history, 130-131 counseling issues, 133-136 Paranoid personality, 40 Passive-aggressive personality, 42 Patients, 8 resources for, 213-214 PCP (angel dust), 78 Personality disorders, 37 classification of, 38-40 Cluster A, 40-41 Cluster B, 41 Cluster C, 41-43 Phobic disorders, 136-138 Planned intervention, 11 Polysubstance abuse, 21 Posttraumatic stress disorder, 139 assessment criteria, 141-142 assessment issues, 142-143 case history, 140-141 counseling issues, 143-144 Powerlessness, 85 Professional enabling, 14-15 Program development administrative support, 198-199 client/family input, 199 collaboration with colleagues, 199 needs assessment, 197-198 philosophy of program, 199-200 program proposal, 200-201 sample program: inpatient unit, 203-211 sample program: outpatient program for schizophrenics, 211-212 staff training, 201-203 Psychosis, 65 R Recovery, 28-33 Relapse prevention, 181 building a social support network, 190-191 cravings and, 192-194 emergencies and, 195-196

factors in treatment outcome, 182 inventory or symptom review and, 194-195 models of, 184-185 precipitants in relapse, 182-184 risk factors in relapse, 185-187 social pressures and, 192 structure in daily life and, 195 warning signs of relapse, 187-190 Relaxation techniques, 134 Resources, list of, 213-214 S Schizoid personality, 40-41 Schizophrenia assessment criteria, 157-158 assessment issues, 159-161 case history, 155-157 characteristics of, 152-154 detoxification for, 161 prevalence of, 151-152 relationship with chemical dependency, 152 sample outpatient program for, 211-212 staff issues, 158 subtypes of, 154-155 treatment interventions for, 161-169 Schizotypal personality, 41 Selective abstraction, 91 Self-identity, 64-65 Self-reference, 93 Serotonin, 63 Shame, 84-85 "Should" or "must" statements, 92 Simple phobias, 136 Sleeping medications, 149 Social phobias, 136-138 Stimulants, 108, 134 Structure in daily life, 195 Substance Abuse Problem Checklist (Carroll), 23, 187 Suicide risk, 103-104 Support groups, 135 Systematic desensitization, 137

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T TERRAP, 135 THC, 25 Thiamine, 174, 179 Tranquilizers, 74 Tricyclic antidepressants, 98-99, 135 Twelve Step programs, 58-59, 73 Type II alcoholic, 45 U Urine testing, 23-25 W Withdrawal Assessment Scale (WAS), 203-204

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HAZELDEN INFORMATION AND EDUCATIONAL SERVICES is a division of the Hazelden Foundation, a not-for-profit organization. Since 1949, Hazelden has been a leader in promoting the dignity and treatment of people afflicted with the disease of chemical dependency. The mission of the foundation is to improve the quality of life for individuals, families, and communities by providing a national continuum of information, education, and recovery services that are widely accessible; to advance the field through research and training; and to improve our quality and effectiveness through continuous improvement and innovation. Stemming from that, the mission of this division is to provide quality information and support to people wherever they may be in their personal journeyfrom education and early intervention, through treatment and recovery, to personal and spiritual growth. Although our treatment programs do not necessarily use everything Hazelden publishes, our bibliotherapeutic materials support our mission and the Twelve Step philosophy upon which it is based. We encourage your comments and feedback. The headquarters of the Hazelden Foundation are in Center City, Minnesota. Additional treatment facilities are located in Chicago, Illinois; New York, New York; Plymouth, Minnesota; St. Paul, Minnesota; and West Palm Beach, Florida. At these sites, we provide a continuum of care for men and women of all ages. Our Plymouth facility is designed specifically for youth and families. For more information on Hazelden, please call 1-800-257-7800. Or you may access our World Wide Web site on the Internet at http://www.hazelden.org.