Self-help treatment for combined addiction and mental illness.

Abstract

New approaches to treating patients with combined mental illness and substance abuse continue to be developed. This rethinking of treatment is particularly important because of the acknowledged organizational barriers to effective management of persons with dual diagnoses and the excessive costs associated with their recidivism. This column describes a model for treatment that combines peer-led self-help from the addiction field with professional treatment from general psychiatry. This approach represents a paradigm shift from the way treatment is applied in the conventional mental health system in that patient peers assume many of the roles that are usually carried out by professionals, and these services are then integrated across levels of care. The model is based on a theoretically grounded perspective on behavioral change. We have evaluated its application in empirical studies in our system of acute inpatient, stepdown, and ambulatory units. This column should help convey how the self-help peer-led approach can be applied to bring about systems-level change in a variety of treatment settings where people with dual diagnoses are encountered, such as large hospital centers, smaller private programs, or multisite health maintenance organizations. The problem Combined substance abuse and mental illness was evident in communitybased populations at the time of the National Institute of Mental Health Epidemiologic Catchment Area survey in 1980‐1985. The survey found that 29 percent of mentally ill persons had substance use disorders. Among psychiatric inpatients, a 1988 New York State survey estimated the prevalence of substance abuse to be 34 percent. In a study the following year at New York City’s Bellevue Hospital Center, our treatment site, we found the remarkably high prevalence of 64 percent of substance use disorders among general psychiatric patients (1). Most notable in terms of likely recidivism was that 38 percent of those admitted to the general psychiatric service were cocaine abusers. Addiction rehabilitation, however, was not integrated into our hospital’s approach to general psychiatric care, and dual diagnosis patients were offered no resources for undertaking recovery from addictive illness. There was no access to peer-led self-help, as in the 12-step programs and drug-free therapeutic communities that were typical of community-based addiction rehabilitation. These circumstances are now widely known to lead to recidivism and a compromised clinical outlook. Furthermore, it is now understood that a material change in the care delivery system is needed to address this population’s needs, and no such adaptation had been made at Bellevue—or at similar institutions.