What can I do?

Guidelines for working with clients who have schizophrenia and substance use problems

The following are some guidelines for working with people who have schizophrenia and substance use problems:

Learn about schizophrenia and about substance use problems
• Obtain a working knowledge of the signs and symptoms of schizophrenia
• Learn about how substance use affects people with schizophrenia -

  • What looks like resistance or denial on the part of a patient/client may actually be a manifestation of negative symptoms of schizophrenia.
  • An accurate understanding of the role of substance use disorders therefore requires a multiple-contact, longitudinal assessment.
Take a tolerant, harm-reduction approach
• In most cases this is more effective than a confrontational, strictly abstinence-based approach

Work with other health and social service providers to create an integrated and coordinated treatment plan
• If you work in the addictions area, work closely with the client's psychiatrist or mental health professional; if you work in the mental health area, work closely with their addictions counselor
• Create a seamless and integrated plan for your client that will address both their mental health and substance use problems

Promote your client's active involvement in their care
• Provide information about the disorder and treatment options, their costs and benefits
• Work with the client to set individualized goals and determine appropriate interventions

Be an advocate - find out about other issues that your client may be dealing with and help them get the supports they may need
• Assist the client to obtain entitlements and other social services such as housing and vocational opportunities
• Encourage and facilitate their participation in social clubs with recreational activities, or in generic community groups and organizations that suit their interests
• Help them link to self-help/peer support resources

Be aware of the patterns of recovery
• Expect crises associated with schizophrenia and have available resources to facilitate stabilization (i.e., crisis intervention, psychiatric consultation)
• Work with the client to detect and identify the early signs of relapse for both schizophrenia and substance use problems and create an action plan
• Take a long-term perspective based on belief in the possibility of recovery
• Help the client work toward an improved quality of life, starting with setting long-term goals

Meet the client where they are
• Be matter-of-fact, accepting, non-judgmental and non-confrontational - building trust is important for recovery
• Present information in simple, concrete terms with examples and use multimedia methods
• In counselling sessions provide frequent breaks as needed and shorter sessions or meetings as appropriate

Involve the family
• Provide information about the disorder. One way is to involve the client's family in psycho-educational groups that specifically focus on education about substance use disorders and psychosis
• Establish support groups of families and significant others
• Be available to answer families' questions about your services
• Respecting patient confidentiality concerns, ask your client if they would agree to family involvement in treatment planning

Selected psychosocial interventions for addiction, specially modified for patients with schizophrenia

• Explore reasons for substance misuse, including relationship to psychiatric symptoms, antipsychotic treatment and feelings of social isolation
• Address patient's motives and degree of commitment towards treatment of both their psychotic illness and their substance misuse
• Adopt concrete problem-solving approach with patient, where appropriate
• Set tasks that are simple and readily achievable (eg, keeping a diary of substance use or psychotic symptoms; regularly taking medication; keeping appointments)
• Focus on specific skills to deal with high-risk situations, and consider use of role play (eg, learning how to say "no" to a dealer or drug-using friends)
• Suggest alternatives to substance use for coping with stressful situations (eg, exercise, contacting a support person)
• Treat comorbid anxiety with behavioural techniques (eg, breathing exercises, progressive muscular relaxation)
• Remain supportive and emphasize any gains made
• Recommend group support
• Enourage participation in alternative activities and contact with non-substance-using peer group (discuss available resources with local community health centre or mental health service)
• Adopt a long-term perspective, with ongoing intervention.

Source: Substance misuse in patients with schizophrenia: a primary care guide Dan I Lubman and Suresh Sundram MJA 2003; 178 (9) Suppl 5 May: S71-S75 www.mja.com.au

Other resources and links:
Treating Concurrent Disorders A Guide for Counsellors - Approaching Concurrent Disorders-CAMH

Psychotherapeutic Medications 2006: What Every Counselor Should Know ( 2006) Published by the Addition Technology Transfer Center Network, and adaptive for inclusion in CSAT's TIP 42: Substance Abuse Treatment for Persons with Co-Occurring Disorders

Substance Abuse in Brief Fact Sheet - Identifying and Helping Patients with Co-Occurring Substance Use and Mental Disorders: A Guide for Primary Care Providers (Vol. 4, Issue 2, 2006). Published by the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration (SAMHSA),U.S. Department of Health and Human Services (HHS). This fact sheet explores the relationship between co-occurring substance use and mental disorders, including the identification of patients with co-occurring disorders and providing or obtaining appropriate treatment for such disorders.