While the barriers to treatment for concurrent disorders are considerable, consumers who persevere with seeking the right kind of treatment from the right kinds of service providers have found that help and understanding can come from many places in life, including the formal service system.
Consumers have emphasized how important it is to feel accepted without judgment by services providers. For providers, this means that services need to be delivered in a spirit of acceptance of all symptoms and experiences related to both schizophrenia and problem substance use. When treatment is provided in a way that respects and values people and their responsibility to choose, it can play a major part in providing people with the foundation they need to needed to achieve recovery1
Services for people with schizophrenia and substance-use disorders are most effective if they involve a variety of interventions addressing the range of biological and psychosocial problems associated with having concurrent disorders.
What kind of treatment is the most effective?
"Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting,"2
People with psychotic illnesses and substance use disorders have said, and research has shown, that the most effective way of approaching the treatment of concurrent disorders is through a single provider who can be trusted to understand and address mental health and substance use problems simultaneously.
Because people with schizophrenia and substance abuse issues have a complex set of interlinked problems and treatment needs, an approach that combines both mental health and addiction services in one program is the most effective.
Integrated treatment is a way of making sure that treatment of both the mental health and substance use problems is smooth, coordinated and comprehensive. It helps to ensure that the client receives help not only with the mental health and substance use problems, but also in other life areas, such as housing and employment. Ongoing support in these areas helps people to3
• maintain treatment successes, like improvements in the symptoms of mental illness and reductions in substance use;
• prevent relapses;
• ensure their basic life needs are being met.
• remain engaged in treatment
• make progress in their recovery.
What does integrated treatment look like?
"Treatment success derives from the implementation of an empathic, hopeful continuous treatment relationship, which provides integrated treatment and the coordination of care through the course of multiple treatment episodes."4
Common features of successful integrated treatment programs include:
• Assertive outreach
to engage people who are often reluctant to come forward for help, support and treatment;
• Motivational interviewing
-based approaches to therapy designed to help people progress toward goals they define for themselves;
• Behavioural approaches
to therapy in which therapists help consumers to identify unhelpful thoughts and behaviours and learn healthier skills and habits
• Family intervention and support
- Therapists often work with one family at a time, but sometimes therapy is offered in a group setting with other families in similar situations. Group members can share feelings and experiences with other families who understand and support them.
• A readiness-to-change approach
- treatment needs to match where people are at in terms of their substance use - are they ready to acknowledge that it's a problem? Are they ready to begin to consider ways of making changes in their use? Are they motivated to take action?
• A focus on a range of areas
that go beyond eliminating symptoms of schizophrenia and substance use, including social, work and housing support;
• A long-term perspective
based upon a belief in the possibility for recovery and toward improving people's quality of life and including realistic, long-term goal setting
• in most cases, a tolerant, harm-reduction focused approach to substance use
rather than a confrontational, strictly abstinence-focused approach.
When people have concurrent disorders, abstinence (completely refraining from using substances) is often the best long-term substance use goal. Continued use of alcohol and/or other drugs may worsen emotional or mental health problems and threaten a person's overall physical and psychological well-being.
However, many people may, at least at first, lack the confidence and skills to decrease or stop their substance use. So, when clinicians work with someone who is struggling with both major substance use and mental health problems, the short-term goal is often to reduce the most harmful effects of substance use while developing a strong working alliance with clients. This trusting relationship can help clients understand the negative effects of their substance use and develop the motivation to change it. This approach - not requiring the person to commit to abstinence as a condition for help - is called harm reduction. Centre for Addiction and Mental Health. Concurrent Disorders: A Resource for Families. 2006
Consumers and families should be able to expect services that are welcoming, accessible, integrated, continuous and comprehensive.
b) Self management
c) What is self management?
Self management means different things to different people. For some people, self management is "whatever we do to make the most of our lives by coping with our difficulties and making the most of what we have". For others, it means "avoiding or minimizing mental health crises through recognizing and acting on danger signals". For many, self management is a key element in their recovery journey. In this section we'll explore what a self management approach can offer to people with schizophrenia and substance use problems.
In dealing with chronic disorders like schizophrenia and substance use, a person's ability to self-manage is an important factor in moving toward recovery. The person becomes informed about their disorders, and they learn strategies for improving their mental and physical health and avoiding a relapse.
"Self management is something we all do. It is whatever we do to make the most of our lives by coping with our difficulties and making the most of what we have.
Applied specifically to people with a schizophrenia diagnosis, it includes the ways we cope with, or manage or minimize the ways the condition limits our lives, as well as what we do to thrive, to feel happy and fulfilled, to make the most of our lives despite the condition."5
When it comes to services, self management means being actively engaged in dealing with your disorder6
. You become an active participant in your care, rather than someone who passively follows recommendations and complies with a treatment plan developed by a health professional. Self management allows and encourages people to participate in setting their own goals and determining the types of interventions that are likely to be helpful for you.
This approach supports a variety of goals, which is important since different individuals will have their own unique set of goals that are meaningful to them.
"We are all different and what works for one person may be useless for another. Therefore, one has to discover one's own ways of improving. Also, it may take many years to become really good at it. But just starting is important: changing the attitude of "passing the buck" and taking the decision to take as full a role as possible in one's own treatment. Set yourself a different course with renewed hope."
Excerpted from a talk by Professor Alec Jenner from the National Voices Forum Report of
1998 Conference on Self management of Schizophrenia
In self management, people learn about the benefits associated with different treatments. They also learn about costs, both the financial costs, as well as the effort and skill that may be required to achieve those benefits.
For self management to be possible, people have to have enough information about their disorder so that they can participate actively in managing the disorder.
d) Self management for people with concurrent disorders
Self management strategies are well developed for some mental health and substance use problems. A number of studies have shown that self management strategies can be very helpful for depression, anxiety and alcoholism. While the field of self management for schizophrenia is less developed, there is increasing recognition that people with serious mental illnesses have an important role to play in the management of the disorder. For example, if people can recognize the triggers and early stages of relapse, actions may be taken to minimize its severity and impact.
"Examples of self management are: increasing your medication if you begin to feel a bit ill, monitoring your progress by writing a diary, going walking if you're angry or agitated, talking to someone close to you if you're depressed, spending some quiet time alone if you've had a hectic day, practising regular relaxation if you often get anxious, planning stress-provoking events at good intervals, learning more about your illness and psychiatry. The list is endless". Excerpted from a talk by Professor Alec Jenner from the National Voices Forum Report of
1998 Conference on Self management of Schizophrenia
Is this approach realistic for people with schizophrenia and substance use problems?
The question of insight is an important consideration in thinking about self management for people with mental health and substance use problems. For someone with concurrent disorders, the degree insight and the ability to make sound decisions about treatment of won't be consistent, but will vary over time.
Most people with mental illness, most of the time, are able to understand information when it is clearly explained, apply this information to making rational decisions and acquire the skills needed to manage their disorders.
Someone who is in the middle of an acute psychotic or substance-related crisis may not be capable at that time of grasping relevant information or balancing the relative costs and benefits of different treatment options.
e) Self management and service providers
The primary goal of all contacts between service providers and people with schizophrenia and substance use problems should be to build and reinforce the person's capacities to manage their own life. That's what self-managed care is all about.
A person who is experiencing a crisis of a mental health and/or substance use disorder may need professional intervention, but that intervention can be informed by a self management approach. Health professionals can work with the aim of supporting people to a more empowered position and promote recovery by improving their ability to make healthier choices.7
When people with schizophrenia and problem substance use seek help, they should be regarded as the experts in the running of their life. Even though they may experience a temporary impairment or delay in that ability, they are the ones who know their experiences and they are the ones who need to learn how to improve the management of their lives.
When people are acutely ill they may need a certain amount of decision-making done for them. This is because:
• They may not have insight into their condition
• They may be ill-informed
• They may have an negative attitude and think recovery is impossible
• They may not be in touch with reality.
However, once people become more stabilized and wellinformed, they should be encouraged to take an increasing degree of responsibility for their own mental health.
Elements of a self management plan can include:
• Self assessment and monitoring
- identifying your own strengths, weaknesses, triggers, talents and needs, e.g. journal writing
• Coping strategies, stress reduction techniques
- e.g. Self-help manuals, tapes, and videos produced by people in recovery on topics such as coping with voices and a description of what helped others heal, exercise, diet, meditation, stress reduction, visualization
• Goal setting
- both long and short term, realistic and manageable, being organized and planning small steps toward larger goals
• Relapse management and crisis planning
f) Relapse management
Managing relapses, or, ideally, preventing them, is a key part of self management.A relapse is an expected part of the recovery process for a person with concurrent disorders. Usually there are warning signs, either of problem substance use or psychotic symptoms, that start long before the relapse. It is possible to identify those warning signs and take action to prevent a relapse.
People with schizophrenia have often said that, over time, they can learn to recognize when they are becoming unwell and learn how to deal with it to avoid a psychotic episode. People become attuned to the "early signs" and many manage to think through and reason with complex, distressing and delusional ideas.
"The first step was to recognize when I was going downhill, and accept I needed to go into hospital before I lost too much control of my behaviour and thinking. A next step was to recognize problems at an even earlier stage and take additional medication, cut down on commitments, and seek medical advice."8
"Nurses helped me to identify my "relapse signature" and find ways of preventing a full-blown relapse."9
A relapse prevention plan often includes:
• An identification of risk factors, such as conflict, social pressure, negative emotional states, stress
• Strategies for dealing with "triggers"
• Strategies to maintain involvement in treatment, especially adherence to medication
• Positive activities and lifestyle choices which increase a sense of balance, physical health and stress management
For worksheets on relapse prevention that you can complete, please see the Tools section of this site.
g) Crisis planning
Advance directives and health care agents
People can extend their decision making beyond the usual point at which a clinician takes over by describing the types of services and medications they will want if and when they are in a crisis. It is also helpful to designate a health care agent to assist the person with decision making during a crisis.
For worksheets on crisis planning that you can complete, please see the Tools section of this site.
h) Self-help and peer support groups
A peer support group is a group of people who all have similar problems. Group members can share their struggles in a safe, supportive environment. People who have recently been diagnosed with concurrent disorders can benefit from hearing about the experiences and coping strategies of others, and many eventually get to the point where they themselves are helping newer members. Group members usually develop strong bonds10
In addition to offering essential tools to assist people with their recovery journey, self-help is a valuable approach to establish positive relationships in the community and maintain connections with other people who have first-hand experience with recovery.
Self-help groups like Double Trouble
, which are specifically geared toward people with concurrent disorders, have helped many people move toward recovery. People find a high level of acceptance, understanding and support from others with similar experiences and problems.
1 New York State Office of Mental Health: Integrated treatment for co-occuring mental health and substance use disorders http://www.omh.state.ny.us/omhweb/ebp/adult_integratedtreatment.htm
2 Minkoff, Kenneth. Changing the World. http://www.kenminkoff.com/article2.html
3 Centre for Addiction and Mental Health. Concurrent Substance use and Mental Health Disorders. 2004 camh.net
4 Kenneth Minkoff. Changing the world: Welcoming, accessible, recovery-oriented, culturally-fluent, comprehensive, continuous, integrated systems of care for individuals and families with psychiatric and substance-use disorders. 2003 http://www.isc.idaho.gov/dcourt/Integration%20of%20Treatment%20Minkoff.pdf
6 Dan Bisker. Self Management in the Mental Health Field. In Visions: BC's Mental Health Journal. No. 18/Summer 2003 http://www.heretohelp.bc.ca/publications/visions/18.pdf
7 Dive, Lisa. Self Management and Addictions. http://www.heretohelp.bc.ca/publications/visions/18.pdf
8 Martyn, D.The experiences and views of self-management of people with a schizophrenia diagnosis. Rethink www.rethink.org/document.rm?id=107
9 Martyn, D.The experiences and views of self-management of people with a schizophrenia diagnosis. Rethink www.rethink.org/document.rm?id=107
10 Concurrent Disorders: A resource for families. Centre for Addiction and Mental Health, Pilot Version, 2006