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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Co-Occurring Disorders:
Integrated Dual Disorders Treatment

Integrated Dual Disorders Treatment Workbook

Chapter 6: Stages of Treatment

INTRODUCTION
For many people with a substance use disorder, it takes many attempts over time to achieve stable remission or abstinence, but most do attain recovery. The vignettes throughout this workbook reflect this expected process of change, which occurs in stages. This chapter describes how integrated dual diagnosis treatment supports the stage-wise process of recovery. It is critical to understand that at different stages of the change process, different types of treatment are helpful. Subsequent chapters in this workbook will give more details about how to help people in each stage of treatment.

HOW CHANGE OCCURS
Change is a process that does not happen quickly or easily. Think about the last big change you made in your own behavior, such as getting on an exercise plan, changing how you interact with others in relationships, or losing weight. Cigarette smoking is a good example, since tobacco smoking is a common addictive problem that many people try to change. If you were a smoker (or have a friend who was), how long did you smoke before you considered that it could be a problem for you? From that point, how long did it take you to decide that smoking was indeed a problem, and that you should stop? This process may take years. From that point, how long did it take to develop a plan and how long before you actually tried to stop? This part of the process may take weeks or months. If you were able to stop, how many times did you have to try before you succeeded? Once you stopped, what did you do to try to keep from smoking again? Most people relapse. Did you ever go back to smoking? Did you go then go through the same process all over again? Perhaps you can see why people go through steps and take a long time to give up smoking, or other substance use.

As people recover from a substance use disorder, they go through a step-by-step process that can be described in stages. Initially, in the pre-contemplation stage, people often do not recognize that their substance use is a problem, even when many of their family and friends do, and so they are not yet considering a need to change. As people become aware that the substance use is a potential problem, they enter the contemplation stage, during which they consider the behavior and the possibility of changing. Once a person makes the decision to change, they enter the preparation stage, where they get committed to change and develop a plan to cut down or stop using substances and develop a plan to do so. In the action stage, they attempt to change by using their plan, and this may occur many times before they are successful. Subsequently, they use strategies to maintain abstinence during the maintenance stage.

STAGES OF TREATMENT
The stages of change described above refer to an internal process, which is often difficult to see or measure accurately from the outside as a treatment provider. However, as people go through the process of changing substance use, they tend to interact with the treatment system in characteristic ways and to use different interventions in the process. For example, what is helpful before they consider their behavior a problem is different from what is helpful when they are actually ready to stop using or after they have stopped and are trying to maintain the change. Stages of treatment therefore refer to the stage-specific behaviors and treatments that have been found to help people with dual disorders in the recovery process. These stages are easily assessed by treatment providers because they describe how people interact with treatment in terms of directly observable behaviors. As persons with dual disorders participate in treatment, they typically go through the different stages of treatment listed in Table 2, described below and in the Stages of Treatment Form at the end of the chapter.

ENGAGEMENT
Engagement is the stage when the client has no relationship with a treatment provider. The client typically does not consider substance use or mental illness symptoms a problem. The clinician's job is to help the client get engaged in treatment. They engage the client by providing helpful outreach and practical assistance to help the client face immediate challenges, such as health problems, financial problems, and so on. Clinicians develop a working-together relationship with the client during this phase by providing help and by using good listening skills and motivational interviewing techniques (see later chapters). Clinicians do not confront clients about their substance use during this stage, though they do try to complete a basic assessment of the substance use. As regular contact with the clinician occurs, the client may progress to the persuasion stage.

VIGNETTE
Corey (Chapter 2) had symptoms of mania and psychosis. He enjoyed smoking cannabis every day, believing it helped him relax. To Corey, smoking pot was an important part of his lifestyle. Despite being hospitalized, he did not feel he had a mental illness, nor did he feel his use of cannabis was a problem in any way. Early in his treatment, he was in the engagement stage.

PERSUASION
As the working relationship develops, if the client does not perceive, acknowledge, or understand his or her substance use or mental illness symptoms, the client is in the persuasion stage. The clinical task is to help the client think about the role of substance use in his or her life. Active listening, exploratory questions about experiences and goals, and education are common techniques. These techniques, often called motivational interviewing, are designed to help the client think about life goals, substance use, mental illness symptoms, and whether substance use or symptoms get in the way of achieving life goals. During this stage, a detailed functional assessment of substance use can be completed (see the next chapter on assessment). Skills for motivational counseling and functional assessment are described in later chapters. During this and later stages, it is often helpful to meet with family members to provide education, get input and include the family in treatment.

VIGNETTE
Tanya (Chapter 1) presents with concerns about depression, rather than drinking, though she has problems with her children, with anxiety, and later with the law that are related to alcohol. With brief counseling, she decides that drinking may be causing problems for her and that she is willing to try cutting back. She comes to treatment in the persuasion stage, and moves rapidly into the active treatment stage.

ACTIVE TREATMENT
Once the client recognizes that substance use is a problem and decides to reduce or stop his use altogether, the client is in the active treatment stage and the goal is to acquire additional skills and supports. For example, the client may need skills to avoid substances (such as assertiveness skills), to socialize without substances (social skills), and to manage feelings without substances (stress management techniques). Similarly, he or she may need new friends, a better relationship with family, and a support group like Alcoholics Anonymous or Dual Recovery Anonymous. Helping the client to learn skills and find supports is called active treatment.

VIGNETTE
Jane (Chapter 4) had paranoia and polysubstance dependence on heroin, alcohol, and cannabis. She had been clean and sober while in treatment 16 years ago, but then relapsed into many years of severe illness and substance dependence. When she was hospitalized at age 33, she became clean and sober again. She moved into transitional housing. She was trying to stay away from substances so she could be involved in parenting her new baby and so she could stay in transitional housing. After going through all the stages of treatment 16 years ago and then relapsing into the engagement stage, where she stayed for many years, she is now back in the active treatment stage.

RELAPSE PREVENTION
When the client is in stable remission (at least six months without substance abuse), the task is to avoid relapsing back into problematic substance use. The clinician can help with a relapse prevention plan, which examines triggers to use substances, such as feelings, people, or situations, and specifies new ways to avoid or handle these cues. Another common task during relapse prevention is to facilitate further recovery by, for example, developing other healthful behaviors and pleasurable activities.

VIGNETTE
Mark (Chapter 12) has schizophrenia and alcohol dependence. After 3 and 1/2 years of treatment, he is sober. He is attending church, building a new relationship with his sister, and considering getting a different job. With his case manager, he spends time planning how to avoid drinking again by avoiding his old drinking buddies, strengthening new sober relationships, and by keeping busy with meaningful activities. He is in the relapse prevention stage.

PROGRESS THROUGH STAGES OF TEATMENT
Most people move through each stage while making progress towards recovery. Some people move steadily, others move in fits and starts, some move very slowly. People often relapse and move backwards and then forwards again. The important point for you to understand is that when people receive integrated dual diagnosis treatment, the treatment needs to correspond to the stage of treatment. In other words, it does little good to work on active treatment skills if the client is not acknowledging a problem with substance abuse. It makes much more sense at that stage to engage the client in a helping relationship and to use motivational counseling to explore the client's experience with substance use.

Recommended reading
There are many good books on stages of change and recovery from substance abuse. We think the best place to start is Motivational Interviewing: Preparing People to Change Addictive Behavior by William R. Miller and Stephen Rollnick (Guilford, 1992). Another helpful reference is Health Behavior Change: A Guide for Practitioners by Stephen Rollnick and others (Churchill Livingston, 1999).

To read more about stages of treatment for persons with dual disorders, see A Scale for Assessing the State of Substance Abuse Treatment in Persons with Severe Mental Illness by Greg McHugo and others (Journal of Nervous and Mental Disease, 183, 763, 1995.)

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