The following abstracts are from journal articles or presentations submitted or in preparation based upon results from the La Frontera Center, Inc., dual diagnosis treatment grants. The current ADMIRE Plus program incorporates information learned
from these grants.
I. NIDA GRANT Reports
Five Years, Twelve Steps, and REBT in the Treatment of Dual Diagnosis
Patricia E. Penn and Audrey J. Brooks
Penn, P. E., & Brooks, A. J. (2000). Five years, twelve steps, and REBT in the treatment of dual diagnosis. Journal of Rational Emotive and Cognitive-Behavior Therapy, 18, 197-208.
A five-year NIDA-funded grant is described that compared client-centered 12-step-oriented and REBT/SMART Recovery-oriented intensive outpatient treatment/partial hospitalization programs with severely impaired clients with dual diagnosis (serious mental illness/substance abuse). Results are presented and suggestions made for applying the findings. (Supported by a grant from NIDA, R01-DA08537 to Penn, and by La Frontera Center, Inc.)
Brooks, AJ, Penn, PE. Comparing treatments for dual diagnosis: Twelve step and self management and recovery. American Journal of Alcohol and Drug Abuse, in press.
The purpose of this study was to compare the effectiveness of 12-Step and cognitive-behavioral (Self-Management and Recovery Training--SMART) approaches for persons with a dual diagnosis of serious mental illness and substance use disorder in an intensive outpatient/partial hospitalization setting. Participants (N=112) were alternately assigned to the two treatment conditions with 50 participants completing the 6-month treatment program. Assessments occurred at baseline, 3 months, and 6 months during treatment, and at 3- and 12-month follow-ups. Analyses were conducted on participants who had completed 3 months of treatment (N=70). The 12-Step intervention was more effective in decreasing alcohol use and increasing social interactions. However, a worsening of medical problems, health status, employment status, and psychiatric hospitalization were associated with the 12-Step intervention. SMART was more effective in improving health and employment status, but marijuana use was greater for SMART participants. Improvements in alcohol use and life satisfaction occurred in both approaches. Covariates associated with treatment outcome were identified, with greater attendance being positively related to outcome. Involvement with the criminal justice system was positively related to treatment completion but negatively associated with medical problems. Less alcohol use, fewer medical problems, and better financial well-being at baseline were associated with better attendance.
Penn, P. E., & Brooks, A. J. (June, 2000). Application of a process evaluation model in dual diagnosis treatment research. Presented at the College on Problems of Drug Dependence Annual Meeting, San Juan, Puerto Rico.
A process evaluation was conducted for a study comparing two intensive day treatment approaches for clients with a dual diagnosis of serious mental illness and substance use disorder. The two approaches were 12-Step and cognitive-behavioral (Self Management And Recovery Training-SMART). An existing process evaluation framework was applied to the presentation of process evaluation results to organize and interpret the findings and test the usefulness of the framework. The framework was found to be a useful tool not only for organizing the results into coherent domains but also for identifying whether each area had been adequately assessed in the process evaluation. Extensive monitoring of implementation integrity facilitated identification and remediation of a persistent client-counselor interaction style difference between the two treatment approaches (12-Step counselors were not as client-centered). Program and counselor characteristics critical in working with the dually diagnosed population were identified. (Supported by a grant from NIDA, R01-DA08537 to Penn, and by La Frontera Center, Inc.)
Penn. P. E., Brooks, A. J., Velten, E., Winningham L., & Parker, J. (In preparation). Methods for dual diagnosis treatment research: Method adherence forms and activity logs.
Although prevalent in mental health research, process evaluation methods are not often utilized or reported in the substance abuse treatment literature. The aim of the present study was to develop process evaluation methods for a study that compared 12-Step and cognitive-behavioral (Self Management And Recovery Training) approaches applied in an intensive day treatment modality for persons with a dual diagnosis of serious mental illness and substance use disorder. The goal was to develop methods of process evaluation that ensured compliance with the general program structure, yet allowed objective comparison of two disparate and exclusive treatment approaches. Two process evaluation methods were designed. A group activity log monitored client performance and participation. A method adherence form assessed staff adherence to program structure and philosophy. The group activity log measured treatment dosage, tracked symptom patterns, compared response to treatment between the two approaches, and examined treatment response by client characteristics. The method adherence form identified staff strengths and weaknesses and suggested areas where additional training was needed. These methods can easily be adapted and utilized by similar types of programs. (Supported by a grant from NIDA, R01-DA08537 to Penn, and by La Frontera Center, Inc.)
Training issues in the treatment of persons with dual diagnosis
A.J. Brooks and P.E. Penn
Brooks, A. J., & Penn, P. E. (June, 2001). Training issues in the treatment of persons with dual diagnosis. The College on Problems of Drug Dependence Annual Meeting, Scottsdale, AZ.
Miller and Brown (1997) have argued for psychologists to play an increased role in the treatment of substance abuse. Part of their argument rests on the notion that clinical styles common in psychological training (e.g., empathy) are determinants of successful treatment outcomes. Cross-training in both substance abuse and mental health issues may also prove critical in dual diagnosis treatment. Dually diagnosed individuals have responded poorly to treatment in substance abuse clinics or mental health facilities that focus on one disorder or another (e.g., Bartels & Thomas, 1991). The current consensus is that the dually diagnosed require unified, integrated treatment. The present study provides evidence supporting the need for cross-training in treating this population. Dually diagnosed individuals (N=112) were randomly assigned to either 12-Step or cognitive-behavioral treatment, SMART. 12-Step counselors had substance abuse treatment experience but no mental health background, while the SMART counselors had a mental health background. These differences in background may have influenced treatment provision. Sixteen of the eighteen client complaints received during the project concerned the non-client-centered style of the 12-Step counselors. SMART participants had higher counselor ratings of weekly psychiatric symptoms. However, 12-Step participants had a greater number of psychiatric hospitalization days. Trends in the data revealed greater psychiatric symptoms and need for psychological treatment for 12-Step clients. One explanation for these findings is that 12-Step counselors were not able to identify psychiatric symptoms in their clients and by extension, did not treat the symptoms adequately. In contrast, 12-Step clients showed greater improvement in alcohol use. A trend for greater marijuana use was also found for SMART clients. These findings suggest that not only integrated treatment but also cross-training in substance abuse and mental health may be necessary with this population. (Supported by a grant from NIDA, R01-DA08537 to Penn, and by La Frontera Center, Inc.)
II. CSAT Grant Reports
Consumer perspectives on dual diagnosis treatment
Brooks, A.J., Gallagher, S., & Penn, P.E.
Brooks, A. J., Gallagher, S. M., & Penn, P. E. Consumer perspectives on dual diagnosis treatment. 110th Annual Convention of the American Psychology Association, Chicago, IL, August, 2002.
Persons with dual diagnosis are a heterogeneous group in terms of psychiatric diagnoses, presenting problems, substance(s) of choice, and the degree of dysfunction exhibited (Osher & Kofoed, 1989). It has been reported that treatment outcomes for persons with dual diagnosis are worse than the outcomes for either serious mental illness or substance abuse alone (Drake, Antosca et al., 1991; Drake, McLaughlin, et al., 1991). Besides dual diagnosis, these individuals are reported to share a number of other challenging characteristics, such as greater social skills impairment, lower level of independent living skills, and higher levels of suicidal, violent, and disruptive behavior, that further contribute to the view that they are more difficult to treat than either the singly diagnosed seriously mentally ill or substance abusers. They are significantly less compliant with medication and treatment, tend to leave treatment prematurely against medical advice more often, and are more relapse-prone than single diagnosis individuals (e.g., Ries & Ellingson, 1990). Further, the course of substance use in this population tends to be chronic and cyclical (Cuffel & Chase, 1994). Given the reported challenges of treating this population, a series of focus groups were conducted with clients with dual diagnosis to obtain their perspectives on treatment and how it might be improved. Thirty-five consumers participated in four focus groups. All participants had a dual diagnosis of substance abuse or dependence and serious mental illness. Ninety-four percent of the clients were currently receiving treatment for dual diagnosis. Males comprised 66% of the sample. The sample was predominantly Anglo (71%). The average length of services was 7.5 years for mental health and 5.6 years for substance abuse treatment. Their current treatment services ranged from outpatient groups, medication management, methadone maintenance, case management, to a day treatment program. Standard focus group methodology was followed in conducting the groups. Questions focused in three principal areas: their experiences living with mental health and substance abuse issues, positive treatment experiences, and negative treatment experiences. The primary themes that emerged across the four groups included: 1) the importance of client-centered services, 2) medication issues, 3) difficulties navigating complex systems, and 4) mental health/substance use treatment integration issues. Client-centered services were described as individualized, flexible, client-driven, long-term, team-based, and supportive. Medication issues focused on the difficulties encountered in trying to find the right medication and/or dosage and the notable benefits when this is accomplished. Problems with accessibility, high staff turnover, poor coordination with the legal system, fragmentation, and insufficient funding were mentioned as system issues influencing their ability to obtain adequate treatment. A lack of staff cross-training in and integration of substance use and mental health treatment provision was also discussed. Secondary themes included self-medication of psychiatric symptoms, poor resources, decriminalization of substance use, personal responsibility for managing their illness, dealing with boredom, and the need for someone with whom to discuss sensitive issues. Dual diagnosis treatment is a relatively new area of service provision, especially for psychologists. However, dual diagnosis is being recognized as the rule rather than the exception in treatment (Minkoff, 2001). Many providers are struggling with how best to treat this population. The current study provides many insights and suggestions for working with this population.
III. ADMIRE Plus Pilot Project Final Report Summary
Project Description
ADMIRE Plus (A+) was one of two pilot projects funded by the state as part of a state initiative to improve treatment in co-occurring disorders sponsored by the Center for Substance Abuse Treatment (CSAT). A+ received the award for Pima county, selected by and funded through Community Partnership of Southern Arizona.
This project was designed to study a small cohort of adults with serious mental illness and co-occurring substance abuse/dependence enrolled in the CPSA system. Clients were accepted into the program regardless of at-risk provider, and were studied throughout a 12-month period. Clients remained in the program regardless of their functional status for the entire year, unless the chose to be disenrolled. Most of the clients accepted were severely impaired in many functioning areas, and were some of the agencies' most difficult clients.
Assessment Methods
Interviews and assessments were done during intake, midpoint, and final month of the year-long grant. These interviews included:
Final Results
Even with the small N (36) for analysis and relatively short treatment time period for this group of clients with severe impairments, some significant improvements were made and other trends were noted.
Comparing the SCID and CAAPE for Assessing Dual Diagnosis
Sandra Gallagher, Ph.D., Julie Feldman, Ph.D., Audrey Brooks, Ph.D., Pratricia E. Penn, Ph.D.
La Frontera Center, Inc., University of Arizona
Gallagher, S. M., Feldman, J., Brooks, A. J., & Penn, P. E. (June 2002). Comparing the SCID and CAAPE for assessing co-occurring disorders. College on Problems of Drug Dependence 64th Annual Scientific Meeting, Quebec City, Canada.
Generating an accurate and complete diagnosis is challenging under typical circumstances. The challenge is even greater when dual diagnoses (i.e., both substance use and mental health disorders, DDx) are suspected. Twenty persons with reported DDx use and mental health disorders, DDx) are suspected. Twenty persons with reported DDx were assessed using both the SCID (Structured Clinical Interview for DSM-IV), used frequently in research, and the CAAPE (Comprehensive Addictions and Psychological Evaluation; Hoffman, 2000), a newer interview designed to assess DDx. Two interviewers assessed 10 respondents each; 5 from a research site and 5 from comparison sites to control for any differences in symptomology and functioning at different sites. Inter-interviewer reliability was established prior to this study. The interviewers were blind to respondents' diagnoses of record. The order of presentation of the interviews was counterbalanced.
The SCID was burdensome taking more than 2 hours to administer. The PTSD module was particularly difficult for many of the respondents. The substance use modules contain several questions that lack specificity. Finally, establishing which diagnosis was primary was difficult without additional questions.
The CAAPE was less burdensome. The average administration took 45 minutes. Some of the CAAPE mental health modules required additional questions to support diagnoses and it did not include a module for psychotic disorders. The CAAPE more thoroughly assessed the DSM-IV substance abuse/dependence criteria and was specific enough to allow the interviewers to establish reliable and complete substance use diagnoses. In addition, each of the mental health modules explicitly asks whether psychiatric symptoms occurred when not using substances.
Recommendations concerning the use of these interviews as well as broader implications for assessment of DDx will be discussed.