Integrated Treatment for Dual Disorders

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Integrated Treatment for Dual Disorders

• Kim T. Mueser, Ph.D.
• Dartmouth Medical School
• Dartmouth Psychiatric Research Center
• Kim.t.mueser_at_dartmouth.edu

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(No Transcript)
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Rates of Lifetime Substance Use Disorder (SUD)
among Recently Admitted Psychiatric Inpatients (N
325) (Mueser et al., 2000)
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Factors Influencing Prevalence of Substance Use
Disorders Client Characteristics

• Higher Rates
• Males
• Younger
• Lower education
• Single or never married
• Good premorbid functioning

• History of childhood conduct disorder
• Antisocial personality disorder
• Higher affective symptoms
• Family history SUD

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Factors Influencing Prevalence of Substance Use
Disorders Sampling Location

• Higher Rates
• Emergency rooms
• Acute psychiatric hospitals
• Jails

• Homeless
• Urban setting (drugs)
• Rural setting (alcohol)

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Clinical Epidemiology

• 1. Rates higher for people in treatment
• 2. Approximately 50 lifetime, 25-35 current
  substance misuse
• 3. Rates are higher in acute care,
• institutional, shelter, and emergency
• settings
• 4. Substance misuse is often missed in
• mental health settings

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Why Focus on Dual Disorders?

• 1. Substance misuse is the most common concurrent
  disorder in persons with SMI
• 2. Significant negative outcomes related to
• substance abuse
• a) Clinical relapse rehospitalization
• b) Demoralization
• c) Family stress
• d) Violent behavior

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• e) Incarceration
• f) Homelessness
• g) Suicide
• h) Medical illness
• i) Infections diseases
• j) Early mortality
• 3. Outcomes improve when substance misuse remits
• 4. Poor treatment is expensive for families
  society

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Poor Outcomes of People with Mental Illness in
Addiction Treatment Settings

• Higher rates of drop out from treatment
• Addiction to more substances
• More problems in legal, social, functional,
  medical outcomes
• Higher relapse rates into addiction
• Lower utilization of self-help groups

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Major Subgroups of Comorbid Clients

• Severely mentally ill - psychotic
• Frequently abuse moderate amounts of substances
• Small amounts of substance use trigger negative
  consequences
• Anxiety and/or depression
• Substance use can cause or worsen symptoms

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• Frequently misuse moderate to high amounts of
  substances
• Personality Disorders
• Antisocial borderline most common
• Frequently abuse high amounts of substances

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Reasons for High Comorbidity Rates of Severe
Mental Illness and Substance Misuse

• Berksons Fallacy
• Self-medication
• Super-sensitivity to effects of alcohol drugs
• Socialization motives
• Acceptance
• Peer pressure
• Facilitates interactions/intimacy

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• Common factors for mental illness and substance
  misuse
• Poverty/deprivation
• Neurocognitive impairment
• Conduct disorder/antisocial personality disorder

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• Self-Medication
• More symptomatic clients dont misuse more
  substances
• Substance selection unrelated to type of symptoms
  experienced
• Types of substances misused unrelated to
  psychiatric diagnosis
• Self-medication may contribute to maintaining
  substance misuse, but probably doesnt explain
  high rates

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• Super-sensitivity Model
• Biological sensitivity increases vulnerability to
  effects of substances
• Smaller amounts of substances result in problems
• Normal substance use is problematic for clients
  with SMI but not in general population
• Sensitivity to substances, rather than high
  amounts of use, makes many clients with mental
  illness different from general population

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Stress-Vulnerability Model
Biological Vulnerability
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Status of Moderate Drinkers with Schizophrenia 4
- 7 Years Later (N45)
Source Drake Wallach (1993)
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CD, ASPD, and Recurrent Substance Use Disorders
N293
Source Mueser et. al. (1999)
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• Support for Super-sensitivity Model
• Clients with concurrent disorders are less likely
  to develop physical dependence on substances
• Standard measures of substance misuse are less
  sensitive in clients with SMI
• Clients are more sensitive to effects of small
  amounts of substances
• Few clients are able to sustain moderate use
  without impairment
• Super-sensitivity accounts for some increased
  comorbidity

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Treatment Barriers

• Historical division of services and training
• Sequential and parallel treatments
• Organizational and categorical funding barriers
  in the public sector
• Eligibility limits, benefit limits, and payment
  limits in the private sector
• Primary/secondary distinction

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Primary/Secondary Distinction

• Often difficult or impossible to make, even with
  extensive observation
• Delays treatment of one disorder
• Is used to shift responsibility from one service
  to another
• Best to assume that both disorders are primary
  until proven otherwise

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Integrated Treatment

• Mental health and substance abuse treatment
• Delivered concurrently
• By the same team or group of clinicians
• Within the same program
• The burden of integration is on the clinicians

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Other Features of Dual Disorder Programs

• No wrong door
• Comprehensive services
• Minimization of treatment-related stress
• Harm reduction philosophy
• Motivational enhancement (e.g., stages of change,
  stages of treatment)

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No Wrong Door

• Multiple doors to services exist in systems
• Substance abuse or mental health services
  accessed through entry to system via multiple
  doors
• Referrals to different services stigmatize
  other disorder decrease chances of engagement
• No referrals to other service providers
  consultation/collaboration needed

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Services Provided

• Comprehensive assessment and monitoring of mental
  health substance abuse
• Concurrent treatment of dual disorders
• Coordination collaboration among treatment
  staff
• Teamwork among treatment providers recognition
  of staff expertise

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Promises of a No Wrong Door Policy

• Successful engagement of most clients in
  treatment
• Systematic assessment of mental health
  substance abuse disorders
• Uniform record keeping
• No need to follow up on referrals
• More effective treatment of concurrent disorders,
  leading to fewer relapses, hospitalizations,
  detoxifications, etc.
• Cost savings

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Challenges of a No Wrong Door Policy

• Need for comprehensive undifferentiated
  training of all clinicians
• How to integrate care while maintaining specialty
  foci?
• Formation of integrated treatment teams
  clinicians from same service or different
  services?
• Fear of loss of professional identity
• Turf issues concern over funding streams that
  target specific disorders
• Need for treatment guidelines to address specific
  dual disorders

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What are the Stages of Treatment?

1. Based on the stages of change Pre-contemplation,
   contemplation, preparation, action, maintenance
2. Stages of treatment Engagement, persuasion,
   active treatment, relapse prevention
3. Not linear progress forward, relapses back
4. Stage of treatment determines primary goal
5. Goals determine interventions
6. Multiple options at each stage

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Overview of Assessment of Substance Abuse in
Clients with Severe Mental Illness
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Detection

• Goal To identify clients who may be experiencing
  problems related to substance use
• Strategies
• 1. Maintain a high index of suspicion
• 2. Explore past history of substance abuse first
• 3. Be aware of clients characteristics related
• to substance abuse (age, sex, antisocial
• personality, etc.)

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• 4. Use laboratory tests
• 5. Carefully monitor clients who use but do not
  misuse substances
• 6. Use self-report screens for substance abuse
• 7. Evaluate clients for common
• consequences of substance abuse
• in SMI

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Common Consequences of Substance Abuse in SMI

• Relapse re-hospitalization
• Financial problems
• Family burden
• Housing instability homelessness
• Non-compliance with treatment

• Violence
• Suicide
• Legal problems
• Prostitution
• Health problems
• Infectious disease risky behaviors

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Classification

• Goal To determine whether client meets criteria
  for a substance use disorder
• Strategies
• 1. Use Clinician Rating Scales for Alcohol
• and Drug Use
• 2. Base ratings on multiple sources of
• information
• Client self-reports

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• Clinician observations
• Reports of other treatment providers
• Reports of significant others
• Records, laboratory tests
• 3. Make rating every 6 months
• 4. Rate based on the worst period over the
• past 6 months
• 5. Stick to the evidence -- dont assume
• consequences of substance abuse
• 6. Gather additional information when
• necessary

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Clinician Rating Scales

• 1. Abstinent
• 2. Use without impairment
• 3. Abuse
• 4. Dependence
• 5. Dependence with institutionalization

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Substance Use Disorders(Based on DSM Series)

• Substance Abuse
• A pattern of substance use resulting in
  significant problems in the areas of social or
  psychological functioning, work, health, or use
  in dangerous situations
• Substance Dependence
• The use of substances that results in development
  of the dependence syndrome

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• Psychological Dependence
• Use of more substance than intended, unsuccessful
  attempts to cut down, giving up important
  activities to use substances, or spending lots of
  time obtaining substances
• Physical Dependence
• Development of tolerance to effects of substance,
  withdrawal symptoms following cessation of
  substance use, use of substance to decrease
  withdrawal symptoms

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Functional Assessment

• Goals To understand clients functioning across
  different domains to gather information about
  substance use behavior
• Domains of Functioning
• 1. Psychiatric disorder
• 2. Physical health
• 3. Psychosocial adjustment (family social
• relationships, leisure, work, education,
• finances, legal problems, spirituality)

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• Dimensions of Substance Misuse
• 1. 6-Month Time-Line Follow-Back Calendar
• 2. Substances misused route of use
• 3. Patterns of use
• 4. Situations in which use occurs
• 5. Reported motives for use
• Social
• Coping
• Recreational
• Structure/sense of purpose
• 6. Consequences of use

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Social Factors for Substance Use

• Does consumer have non-substance using peers?
• Is substance use serving to maintain a
  pre-existing social network?
• Is substance use facilitating social contacts
  with a new social network?
• Can person resist offers to use substances?
• Is the person lonely?

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Common Symptoms Self-Medication

• Depression, suicidal thoughts
• Anxiety, nervousness, tension
• Hallucinations
• Delusions of reference paranoia
• Sleep disturbance

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Recreational/Leisure Substance Use

• Boredom/relaxation as motivation for using
  substances
• What does the client do for fun?
• Hobbies, sports?
• What is persons involvement with others in
  recreational activities?
• Does the person not participate in activities
  which he/she previously did?

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Other Motivating Factors for Using Substances

• Escape from unpleasant memories of psychosis
  (sealing over)
• Increased unstructured time due to dropout from
  school or not working
• Demoralization due to shattering of personal
  goals assault on self-esteem
• Ready access to money through family, disability
  income
• Normal rebelliousness of delayed
  adolescence/early adulthood

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Functional Analysis

• Goal To identify factors which influence or
  control substance use behavior
• Constructing a Payoff Matrix
• 1. List advantages disadvantages of using
• substances, advantages disadvantages of not
  using
• 2. Use all available information from functional
• assessment
• 3. Consider advantages disadvantages from the
• clients perspective
• 4. View different reasons listed as hypotheses
  about maintaining factors, not established facts
  reasons may change as new information emerges
• 5. If client is using, the pros of using cons
  of
• not using should outweigh the pros of not
• using cons of using

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Pay-Off Matrix
Using Substances
Not Using Substances
Advantages
Disadvan-tages
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Common Advantages Disadvantages of Using
Substances Not Using
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Examples of Interventions Based on the Payoff
Matrix
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Treatment Planning

• Goals To determine which interventions are most
  likely to be effective how to measure outcome
• Steps
• 1. Engage the client significant others
• Assess motivation to change
• Select target behaviors, thoughts, emotions to
  change
• Identify interventions to address targets
• Choose measures to assess effects of intervention

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What do We do During Engagement?

• Goal To establish a working alliance with the
  client
• Clinical Strategies
• 1. Outreach
• 2. Practical assistance
• 3. Crisis intervention
• 4. Social network support
• 5. Legal constraints

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What do We do During Persuasion?

• Goal To motivate the client to address substance
  abuse as a problem
• Clinical Strategies
• 1. Psychiatric stabilization
• 2. Persuasion groups
• 3. Family psychoeducation
• 4. Rehabilitation
• 5. Structured activity
• 6. Education
• 7. Motivational interviewing

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What do We do During Active Treatment?

• Goal
• To reduce clients abuse of substance
• Clinical Strategies
• 1. Self-monitoring
• 2. Social skills training
• 3. Social network interventions
• 4. Self-help groups
• 5. Substitute activities
• 6. Cognitive-behavioral techniques to address
• High risk situations
• Craving
• Motives for substance use

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What do We do During Relapse Prevention?

• Goals
• To maintain awareness of vulnerability expand
  recovery to other areas
• Clinical Strategies
• 1. Self-help groups
• 2. Cognitive-behavioral supportive
  interventions to enhance functioning in
• Work, relationships, leisure activities, health,
  quality of life

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Recovery Mountain

• Combat demoralization related to relapses
• Reframe relapses as part of road to recovery
• Dont loose sight of gains made between relapses
• Learning experience, modify relapse prevention
  plan

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Stages of Substance Abuse Treatment

• 1. Pre-engagement No contact with a counselor.
• 2. Engagement Irregular contact with a
  counselor.
• 3. Early Persuasion Regular contact with a
  counselor, but no reduction in substance misuse.
• 4. Late Persuasion Regular contact with a
  counselor and reduction in substance misuse (lt 1
  month).

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• 5. Early Active Treatment Reduction in substance
  use (gt 1 month).
• 6. Late Active Treatment No misuse for 1-6
  months.
• 7. Relapse Prevention No misuse 6-12 months.
• 8. Remission No misuse for over one year.

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What is Motivation?

• Motivation can be understood not as something
  that one has, but as something that one does. It
  involves recognizing a problem, searching for a
  way to change, and then beginning and sticking
  with that change strategy.
• - W.R. Miller

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Motivational Interviewing

• Goal
• To create a salient dissonance or discrepancy
  between the persons current substance abuse
  behavior and important personal goals.
• Core Principles
• 1. Express empathy
• 2. Establish personal goals
• 3. Develop discrepancy
• 4. Roll with resistance
• 5. Support self-efficacy

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Expressing Empathy

• Goal
• To understand the clients world
• Strategies
• Active listening skills
• Good eye contact
• Responsive facial expression
• Body orientation
• Verbal and non-verbal encouragers
• Reflective listening
• Asking clarifying questions
• Avoiding challenges, expressing doubt, judgment,
  and unsolicited advice

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Establishing Personal Goals

• Goal
• To establish personal, meaningful goals that the
  client wants to work towards
• Strategies
• Talk with clients about their
• Aspirations
• Thoughts about how things could be different
• Fantasies

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• Get to know what the client was like in the past,
  such as
• Preferred activities
• Admired people
• Personal ambitions
• Dont discourage ambitious goals

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Examples of Goals

• Finding a job
• Completing high school
• Finding a girlfriend
• Getting married
• Rekindling a relationship with an old friend
• Going fishing with ones father

• Getting ones own apartment
• Resuming parenting responsibilities
• Re-establishing relationships with siblings
• Handling ones own money
• Buying a car

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Developing Discrepancy

• Goal
• To develop a salient discrepancy between the
  clients personal goals and current substance
  abuse behavior
• Strategies
• Use the Socratic Method to help clients reach
  their own conclusions
• Break large, long-term goals into smaller, more
  manageable steps
• Use questions to explore with clients how
  substance abuse may interfere with achieving
  personal goals
• Avoid direct argumentation

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Rolling with Resistance

• Goal
• To overcome resistance to change in substance
  abuse behavior
• Strategies
• Avoid over-pathologizing resistance is normal
• Rather than opposing resistance, explore it
• Identify specific concerns about attaining
  sobriety and problem solve about these concerns

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Supporting-Efficacy

• Goal
• To foster hope in clients that they can achieve
  desired changes
• Clinical Strategies
• Express optimism that change is possible
• Reframe prior failures as examples of clients
  personal strengths and resourcefulness to cope
  with problems such as

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• Homelessness
• Trauma
• Persistent psychotic symptoms
• Time spent in jail
• Acknowledged past setbacks while remaining
  positive about possible change
• Review examples of clients achievements in other
  areas

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Rationale for Group-Based Treatment for Clients
with Co-Occurring Disorders

• Substance abuse frequently occurs in a social
  context
• Opportunity for social support
• Development of a new, healthier social networks
• More economical than individual treatment
• Greater variety of feedback to clients
• Modeling available from clients who have
  progressed to later stages of treatment

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Common Themes of Group Treatments for
Co-Occurring Disorders

• Education about effects of substance abuse
• Non-confrontational
• Avoidance of high levels of negative affect in
  group
• Fostering social support between group members
• Encouraging attendance at self-help groups for
  substance abuse
• Addressing problems related to mental illness

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Different Models of Group Intervention for Dual
Disorders

• 12-Step
• Education/supportive
• Social skills training
• Stage-wise
• Persuasion groups
• Active treatment groups

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Problems with Self-Help Groups

• Sponsorship
• Spirituality and delusions
• Abstract concepts
• Inability to relate to losses
• Early stages of treatment
• Poor social skills
• Paranoia
• Medication as a drug

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Self-Help Approach

• Present as one option
• Go meeting shopping
• Dont forget about the mental illness
• If it doesnt work, dont push it

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Persuasion Groups

• Primarily for persuasion stage
• Keep short (or take a break)
• Co-facilitated
• Open format
• Non-confrontational
• Recurrent use common
• Refreshments

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Persuasion Groups

• Peer role models
• Self-help materials not useful
• Psychoeducation about substance abuse mental
  illness
• Weekly meetings
• Use of hospitalizations, trouble with the law,
  etc.

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Persuasion Groups

• Group Guidelines
• Confidentiality
• Alcohol drug use
• Active psychosis
• No disruptive behavior
• Member check-in

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Persuasion Groups

• Topics
• Guest speakers
• Genograms
• War stories
• Skills training
• Printed materials

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Active Treatment Groups

• Stages of active treatment/relapse prevention
• Co-facilitated
• Weekly meetings
• More confrontational
• Peer role models
• Self-help materials helpful

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Active Treatment Groups

• Topics
• Triggers high risk situations
• Skills training, anger management, assertiveness,
  coping, etc.
• Relaxation imagery
• Stress management

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Social Skills Training Groups

• Primary goal is to teach new skills, not foster
  insight
• Multiple training sessions conducted weekly
• Sessions conducted by 2 leaders following
  pre-planned curriculum
• Planned generalization of skills into clients
  natural environment

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Stage-wise Skills Training

• Appropriate at all stages of treatment
• Early stages (engagement, persuasion) focus on
  motives for using substances
• Later stages (active tx., relapse prevention)
  also address high risk situations, including
  refusal skills

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Motives for Substance Use and Relevant Skills

• Socialization conversational skills, making
  friends
• Leisure recreation developing new recreational
  activities
• Coping expressing negative feelings, cognitive
  restructuring to address anxiety depression

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High Risk Situations

• Offers to use at a party
• Running into a former dealer
• Feeling depressed or anxious
• Invitation to use with boy/girlfriend
• Money or paycheck in pocket

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When to Use Stage-wise or Skills Training Groups

• Both can be useful encourage clients to try both
  types
• Stage-wise groups more abstract, process oriented
• Skills training groups more concrete, easier for
  clients with cognitive impairments

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Why is Family Work with Dual Disorders Important ?

• Many DD clients have contact with family members
  who provide support and assistance
• Caregiving burden is increased when clients have
  DD
• Loss of family support is a major contributor to
  housing instability and homelessness in DD
  clients

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• Relatives may unintentionally encourage substance
  abuse in DD clients
• DD clients and their relatives often know little
  about mental illness and substance use
  interactions
• Family intervention is effective for both
  disorders

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Combined Results of Family Intervention Programs
on 2-Year Cumulative Relapse Rates in
Schizophrenia (11 Studies)
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Goals of Family Intervention for DD

• Educate family members about mental illness,
  substance abuse, and their treatment
• Increase coping skills for all family members
• Increase social support
• Decrease burden of care on family members
• Decrease stress on clients
• Decrease substance use
• Improve client functioning
• Decrease hospitalizations homelessness

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Overview of Intervention

• Two treatment modalities
• Behavioral Family Therapy (BFT) (time-limited)
• Multiple-family groups (time-unlimited)
• BFT for psychoeducation, communication skills,
  problem solving skills
• Multiple-family groups for additional
  psychoeducation social support
• BFT precedes multiple-family groups
• Clients relatives involved in all sessions

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Goals of BFT

• To establish a working alliance between the
  treatment team family
• To provide education to family members about
  mental illness, substance abuse, the their
  treatment
• To enhance family coping through
• Improved communication
• Teaching problem solving skills

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Format of BFT

• Individual family sessions
• Relatives clients included
• Open door policy for reluctant participants
• One hour sessions
• Sessions conducted on a declining contact basis
• Treatment is long-term, not short-term
• Focus is on learning new information skills,
  not fostering insight

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Phases of BFT

• Phase of BFT Client Stage of Sessions
  Treatment
• 1. Connecting Engagement 1-3
• 2. Assessment Engagement 2-5
• 3. Psychoeducation Persuasion or 6-8
• active treatment
• 4. Communication Persuasion, active 1-6
• skills training treatment, or relapse
• prevention
• 5. Problem-solving Persuasion, active
  5-15 treatment, or relapse
  prevention
• 6. Termination Active treatment or 1
• relapse prevention

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Engaging the Family

• Be respectful, non-judgmental, empathic
• Explain you want to help family members become
  members of the treatment team
• Describe goals of family program as education,
  reducing relapses, helping client independence
• Allow relatives to vent tell their story

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Assessment of the Family

• For Each Family Member
• What do they understand about the disorders?
• What are their short-term goals?
• What are their long-term goals?
• What interferes with obtaining their goals?
• For the Family as a Unit
• What are their strengths and weaknesses?
• What deficits do they have in communication
  skills?
• What deficits do they have in problem solving
  skills?

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Principles of Psychoeducation

• Education is interactive
• Use multiple teaching aids
• Connote client as the expert
• Elicit relatives experience understanding
• Avoid conflict confrontation
• Education is a long-term process
• Evaluate understanding
• Review materials as often as possible

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Educational Topics

• Schizophrenia/schizoaffective/bipolar
• Medications
• Stress-vulnerability
• Role of the family
• Basic facts about alcohol drugs
• Alcohol drugs Motives consequences
• Alcohol drugs Treatment
• Infectious diseases
• Communication skills

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Communication Skills

• Communication mental illness
• Improving communication
• Get to the point
• Keep communications focused
• Speak clearly
• Use feeling statements
• Speak only for yourself
• Focus on behavior

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Communication Skills

• Other Communication
• Listening
• Eye Contact
• Voice Tone
• Facial Expression
• Key Communication Skills

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Communication Problems That Warrant Skills
Training

• Frequent fights (loud voice tone, anger, strong
  irritability that derails family work)
• Pejorative put-downs
• Snide, sarcastic, caustic comments
• Lack of verbal reinforcement between members
• Difficulty being specific when talking about
  feelings and behavior

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Problem Solving

• 1. Define the Problem
• 2. Brainstorm
• 3. Evaluate Solutions
• 4. Choose Best Solution or Combination
• 5. Plan on How to Implement Solution
• 6. Follow up Plan

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Format of Problem Solving

• Chairman leads family through steps of problem
  solving
• Secretary records problems solving efforts
• Focus is on getting all members input AND
  sticking to steps of problem solving
• If at first you dont succeed, problem solve
  again
• Always schedule a follow-up meeting

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Examples of Topics for Family Problem-Solving

• Identify alternative socialization outlets
• Responding to offers to use substances
• Determining strategies for dealing with
  persistent symptoms
• Exploring alternative recreational activities
• Finding work or other meaningful activities

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Avoiding the Blame/Demoralization Trap

• Dont blame the client for substance abuse or
  relapses because
• Substance abuse is a disorder for which clients
  are no more responsible than their primary
  psychiatric symptoms
• Clients with most severe substance abuse need
  professional help the most many others improve
  spontaneously
• Remember that the clients are doing the best they
  can

101

• To avoid demoralization
• Remember integrated treatment works in the long
  run
• There is usually no obvious best solution
• Adopt a collaborative-empirical approach to
  treatment
• View relapses as an inevitable part of the
  recovery process
• Develop a case formulation based on a functional
  analysis to guide treatment

102
Clinical Resources

• Bellack, A. S., Bennet, M. E., Gearon, J. S.
  (2007). Behavioral Treatment for Substance Abuse
  in People with Serious and Persistent Mental
  Illness. New York Taylor and Francis.
• Center for Substance Abuse Treatment. (2005).
  Substance Abuse Treatment for Persons With
  Co-Occurring Disorders. (Vol. DHHS Publication
  No. (SMA) 05-3922). Rockville, MD Substance
  Abuse and Mental Health Services Administration.
• Centre for Addiction and Mental Health. (2001).
  Best Practices Concurrent Mental Health and
  Substance Use Disorders. Ottowa Health Canada.
• IDDT Toolkit http//www.mentalhealth.samhsa.gov/c
  mhs/communitysupport/toolkits/default.asp
• Graham, H. L., Copello, A., Birchwood, M. J.,
  Mueser, K. T. (Eds.). (2003). Substance Misuse in
  Psychosis Approaches to Treatment and Service
  Delivery. Chichester, England Wiley.
• Graham, H. L., Copello, A., Birchwood, M. J.,
  Mueser, K. T., Orford, J., McGovern, D.,
  Atkinson, E., Maslin, J., Preece, M. M., Tobin,
  D., Georgion, G. (2004). Cognitive-Behavioural
  Integrated Treatment (C-BIT) A Treatment Manual
  for Substance Misuse in People with Severe Mental
  Health Problems. Chichester, England John Wiley
  Sons.
• Mercer-McFadden, C., Drake, R. E., Clark, R. E.,
  Verven, N., Noordsy, D. L., Fox, T. S. (1998).
  Substance Abuse Treatment for People with Severe
  Mental Disorders A Program Manager's Guide.
  Concord, NH New Hampshire-Dartmouth Psychiatric
  Research Center.
• Mueser, K. T., Gingerich, S. (2006). The
  Complete Family Guide to Schizophrenia Helping
  Your Loved One Get the Most Out of Life. New
  York Guilford Press.
• Mueser, K. T., Noordsy, D. L., Drake, R. E.,
  Fox, L. (2003). Integrated Treatment for Dual
  Disorders A Guide to Effective Practice. New
  York Guilford Press.
• Roberts, L. J., Shaner, A., Eckman, T. A.
  (1999). Overcoming Addictions Skills Training
  for People with Schizophrenia. New York W.W.
  Norton.

103
Research Reviews

• Brunette, M. F., Mueser, K. T., Drake, R. E.
  (2004). A review of research on residential
  programs for people with severe mental illness
  and co-occurring substance use disorders. Drug
  and Alcohol Review, 23, 471-481.
• Cleary, M., Hunt, G., Matheson, S., Siegfried,
  N., Walter, G. (2008). Psychosocial
  interventions for people with both severe mental
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