New Initiatives in the Treatment of the Chronic Patient

with Alcohol/Substance Use Problems

Kathleen Sciacca, M.A., Executive Director, Sciacca
Comprehensive Service Development for Mental Illness, Drug
Addiction and Alcoholism, (MIDAA), New York City, 212-866-
5935.

Development of Program

It is clearly evident that the lack of comprehensive treatment
programs for persons with mental illness and alcohol/drug use
problems has created a treatment dilemma in our mental health
programs across the nation. It is also clear that there is movement
to address this dilemma, and that a change in attitude among
mental health professionals is taking place. For example, in my
own travels in the mental health system I have heard the argument
change from "We are not supposed to treat alcohol and/or drug
problems in the mental health setting", to "Large numbers of our
mentally ill patients also have problems with alcohol and drugs,
how can we treat them, what can be done?"

Two and one-half years ago when I began work at one of Harlem
Valley's Day Treatment programs I set out to answer the latter
question. Through working with the patients themselves and by
implementing a program within an existing psychiatric setting I
began to find answers to that question. The answers that were
discovered proved worthy of comprising a comprehensive
treatment and proved to be applicable across separate treatment
sites and multiple program formats. The first group, which began
in December 1984, grew to eleven groups across six treatment
sites, and includes clinics, day treatment, continuing treatment and
residential program settings. Programs had to take place in our
own treatment sites and utilize existing staff, without additional
funds or special staffing. This led to the development of a
treatment and group leadership approach that did not require
extensive training in the area of substance abuse and alcoholism.

Treatment Approach and Philosophies

The issue that became most apparent when discussing substance
abuse cases and issues with staff was the lack of knowledge or
understanding of alcoholism and drug dependency as a disease--in
effect, as an illness with symptoms that need to be brought into
remission. Information about the disease concept of the use and
abuse of various substances was disseminated to both staff and
patients throughout our facilities, as an initial (and now an
ongoing) approach to focusing attention on the problems. With the
advent of a treatment group and a rise in information about the
topics, some staff began to take interest in beginning a group in
their service area.

In the summer of 1985 the administration formally identified staff
members at each of the six sites who expressed an interest in
providing group programming in their service area. The identified
staff began meeting monthly for education, training, and the
development and implementation of program initiatives. i.e.
assessment tools, etc. The same staff members took on the
responsibility of presenting educational materials to co-workers at
their program sites. Staff reported feeling comfortable in providing
treatment for patients with substance use problems through the use
of an exploratory approach to understanding and treating these
patients. Staff are not expected to present themselves as substance
abuse experts when conducting treatment groups. Instead they can
be comfortable in learning from and with the patients about many
issues relevant to mental illness and concomitant substance use
problems. However, staff do have a working understanding of the
scope of the problem of substance use, its genetic predisposing
factors, issues of tolerance levels, psychological dependencies, and
the issues specific to combining these problems with the symptoms
of a chronic mental illness. Staff and patients together begin to
identify the interaction effects of these dual disorders, and it
becomes clear to the patients that they are not being judged as ill
behaved, or being sent away to another treatment program, or
having to relate to a staff member who feels hopeless about their
prognosis because they have a substance use problem. This clarity
enables patients to trust the staff and their peers in the treatment
setting, and to speak openly about their problems in a supportive
environment.

Treatment Methods and Content

Few mental health professionals would argue with the fact that
heavy confrontation, intense emotional jolting, and discouragement
of the use of medication are detrimental approaches to the
treatment of a chronically mentally ill person. Yet efforts to treat
these patients have consisted mainly, of referring them to agencies
that treat primary substance abusers who do not have a chronic
disorder, where in many cases the above treatment methods and
strategies are employed. It is no wonder that there is a great deal of
resistance from these patients to following through with these
referrals, as well as refusal by these agencies to take responsibility
for an ongoing psychiatric disorder.

The treatment method we have found effective features non-
confrontational approach. The group process focuses upon
educational materials and permits each patient to discuss substance
use issues in an impersonal way when this is more comfortable.
Treatment staff do not seek to catch patients in lies; rather the
objective is to engage patients in a process that offers a variety of
information and points of view on the use of drugs and alcohol.

Peer support evolves out of each patient's eventual openness in
discussing issues that are important in their lives as well as the
relationship between substance use and other variables. Group
leaders and members assist individuals to gain insight into the
dynamics and patterns of the use of the substances when this is
applicable. One of the essential learning experiences is the
relationship of the use of drugs or alcohol to each patient's
psychiatric symptoms. Group members begin to identify these
interaction effects in others and in themselves.

Since group members are often resistant about attending self-help
groups such as AA and NA, the model includes inviting AA and
NA speakers to the group sessions to conduct open meetings and to
tell their story to the group. These sessions are always highly
effective, and they enable patients to benefit from identifying with
recovering substance users even though they may not be
comfortable or able to follow a full program of AA or NA. As a
result of these sessions some patients do begin to attend these
support groups in addition to our program.

Content areas of the educational process include areas that are
unique to patients with a chronic mental illness, such as mixing
medication with other substances, as well as areas that are similar
between primary substance abusers and our patients-- for example,
the fact that in many cases the use of the substances begins to
control the patient's motivation and behavior versus the patient
being in control of the use of the substance. Recurring themes such
as the need to find new social networks are addressed through
general discussion as well as through each individual's discussion
of his or her own problems.

Overview of Program

Substance abuse groups are integrated into regular programming.
For example, a patient in the day treatment program will attend all
other programming as usual, except that he or she will attend a
substance abuse group once or twice a week in lieu of another
scheduled activity. In a clinic program patients will visit a
medicating physician (where applicable), have regular sessions
with a primary therapist, and attend the substance abuse group
once a week. Patients are not segregated or removed from regular
program activities. Communication between group leaders and
primary therapists ensues regarding the patient's progress in the
group. However, criteria for improvement include many areas and
are not confined only to achievement of abstinence. A patient's
ability to discuss his or her problems or usage openly may be a
very important criterion for a patient who has kept his/her
substance use a secret. Various insights that a patient may gain are
considered progress. Collaborating with other treatment staff must
not have the tone of reporting on a patient's substance use;
therefore criteria need to be carefully thought out and conveyed to
others.

Treatment groups last from forty-five minutes to one hour.
Numbers of patients in groups vary from program to program;
eight seems to be an optimal number of members. Groups should
be kept to manageable size so that patients may explore their issues
in depth when necessary and so that each patient has an
opportunity to participate verbally in each session.

A brief alcohol and drug screening tool is presently in use for all
intakes at Harlem Valley. The questions include clinical intuition
as well as historical information, so that the patient in the denial
phase of his or her problem does not have the problem go unnoted.
Where positive signs of substance use problems are identified,
liaisons at the facility are notified of this, so that they may follow
the case until a decision is made about referring the patient to the
substance use treatment group. If a patient is referred he or she is
interviewed by the group leader(s). This interview is really the
beginning of the treatment process and is a method of establishing
a purpose for the patient's participation in the group, be it to view
educational materials or to work on an acknowledged problem.
The interview focuses on the patient's potential contribution to the
group as well as what is expected of a participant.

The assessment questionnaire is an in-depth interview of many
aspects of a patient's substance use history and present usage.
Treatment guidelines are included so that therapists who are
unfamiliar with substance abuse treatment can integrate its goals
and objectives into the treatment plan. The assessment takes place
during the process of treatment and is not used for screening.
We recognize the need for specific substance abuse treatment
programs such as inpatient detoxes, rehab programs that last at
least several weeks, adjunct support groups, etc. To generate
successful referrals we have developed an interview for adjunctive
treatment services. These agencies are visited by liaisons and
assessment of the agencies' compatibility to our patients is
obtained. We would like this effort to result in less rejection for
our patients and more success outcomes where and when patients
do engage in these programs.

Administrative Support

A program of this scope and pioneering experimentation cannot be
implemented or sustained without the support of administrators in
a given agency. The Harlem Valley administration including our
Executive Director, Clinical Director, Director for Community
services and Associate Director for Community services, to name
but a few, are innovators within our field. Without their foresight
and support in allowing a program such as this to progress, I could
not report to you that these patients can improve along numerous
criteria, and these programs can take place within our existing
mental health programs.

This article is a reprint from TIE-Lines, Published by the Information Exchange
on Young Adult Chronic Patients, Bert Pepper, M.D., Executive Director Vol.
1V, No. 3, July 1987

Also printed in AID BULLETIN, ADDICTION INTERVENTION WITH THE
DISABLED, Fall 1987, Vol 9, and in AMERICAN ASSOCIATION FOR
PARTIAL HOSPITALIZATION BULLETIN, Vol. XXI, No. 1, JANUARY
1988

COPYRIGHT, 1988 Kathleen Sciacca

Copyright ©1996 Kathleen Sciacca