Interview with Kenneth Minkoff, MD
Athealth.com: What would constitute an initial intervention, or, what comes next?
Dr. Minkoff: One of the initial individual interventions is to see whether or not this person would be willing to participate in a group. In the group, being committed to abstinence is not required. However, the patient needs to be willing to engage in a discussion about what his substance
use related choices are and how to make the best choices for himself. Using peer influence can help people make better choices over time. Most people know that it is a bad idea for a person with a mental illness to use substances. People are willing to recommend better choices to a friend even if they are not particularly willing to make better choices for themselves at that time.
The other thing we do within the individual integrated intervention is to look for opportunities to develop contingency management strategies that might help the individual to make better choices.
It is a challenge to figure out how to do this in a way that is supportive but not coercive, and that facilitates better decision making without being overly controlling. This usually involves a process of trial and error.
Athealth.com: Can you recommend some practical contingency management strategies?
Dr. Minkoff: Some strategies for doing this can include engaging significant collaterals (families who may control contingencies in the person's life like visits or money that the person may want to earn).
We can also use payeeship strategies
to help create behavioral structures for earning additional money or additional control over money.
If the person is willing to participate in these kinds of structures, these strategies can be used to help the person develop motivation to learn skills to reduce substance use. As time goes on, the person may become more interested in changing their substance use pattern.
Then, we can begin individual and group interventions to teach them the specific skills for changing their substance using behavior.
Nevertheless, as time goes on, this person may require a specific episode of alcoholism treatment. His mental illness has stabilized. but he keeps drinking. Let's assume that he has tried on a number of occasions to stop, and he realizes he is not in control. He may be appropriately referred for alcoholism treatment in the addictions system.
Athealth.com: What about inpatient treatment for this individual? Are programs in the addictions system typically set up to accommodate the needs of dually diagnosed patients?
Dr. Minkoff: There are models for assuring that routine alcoholism treatment programs have a level of dual diagnosis capability, where a relatively well functioning person with schizophrenia can be well accommodated in such a treatment environment.
There are also dual diagnosis enhanced programs which have higher levels of staffing and a more integrated mental health component that can more easily accommodate people with serious mental illness who, at baseline, have psychiatric disabilities that would make it harder for them to learn the skills and receive the support they need in order to function
in an addictions treatment environment. He may go in for such an episode of care.
In some instances, people like the man from the vignette may actually need an extended, sober, dual diagnosis residential program. Of course, he may not need that; in fact, most people tend not to need this. But there is literature that has emerged on what is called
the modified therapeutic community of extended residential treatments for very impaired people with substance dependence and serious mental illness. This work comes under the auspices of Stan Sachs of New York and George DeLeon of Pennsylvania who have talked about long-term treatment interventions, which are successful in a subset of the total
population of people with co-occurring disorders. These are fairly high-end, high-cost interventions, and it is not totally clear where they fit in to the total system of care. However, they certainly have value for those people who can use them in systems where they are available.
Most people get sober through shorter episodes of care, in both psychiatric and addictions settings, with on-going integrated case management, which continually supports the patient in working on developing and enhancing recovery skills.
Page last modified or reviewed on March 8, 2009
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