Interview with Kenneth Minkoff, MD
Athealth.com: Is there work available that describes how these dual diagnosis enhanced programs or similar resources work?
Dr. Minkoff: A number of textbooks and workbooks describe the process of working with the mental health and addictions components. Of note is a forth-coming work by Rhonda McKillup from Spokane, Washington. Hazelden has published a several workbooks; and Dennis Daley from Pittsburgh has written materials on developing group interventions for people with mental illness.
Beyond that, there are two well known 12-step programs for people with dual disorders, in addition to generic 12-step treatment. These are Dual Recovery Anonymous--which is
associated with Tim Hamilton --and Double Trouble in Recovery which is associated with Howie Vogel and the Mental Health Empowerment Project out of the New York State Office of Mental Health.
Also, there is a recent update of a book called Dual Diagnosis: Counseling the Mentally Ill Substance Abuser, by Kattier Evans and J. Michael Sullivan, which provides information on the application or modification of dual diagnosis counseling interventions in addiction treatment episodes of care (outpatient, intensive outpatient, day treatment, residential) for people with various kinds of mental illnesses.
Athealth.com: How would you describe the most essential clinical strategies to employ when working with this population?
Dr. Minkoff: - Establish a continuous therapeutic relationship.
- Determine how to balance what the person needs in terms of case management and care with a level of expectation and contracting that can help the person bear some of the consequences of their substance use in a way that fosters change and is supported by the therapeutic relationship.
- Continue the model of integrated dual primary treatment or treat the mental illness in an appropriate way and continue to focus appropriately on the substance use disorder.
- Adopt stage or phase specific treatments. Treatment and interventions should not only be diagnosis specific, but they should also be stage or phase specific. For example, if people are pre-motivational about changing their substance use, then do pre-motivational interventions, not active treatment interventions, to move them along the stages of change
- Within a managed care system, match the interventions to the most appropriate level of care. Most of the time treatment takes place in on-going treatment community-based settings where providers use episodes of care judiciously, when people actually need and can benefit from them.
Athealth.com: Is treatment compliance more so an issue for patients with co-occurring disorders than those who are not dually diagnosed?
Dr. Minkoff: People tend to be non-adherent to treatment recommendations for both mental illness and substance use disorders . When people have both disorders, they are more likely to be non-adherent to one or both. Non-adherence to one tends to lead to non-adherence to the other.
Athealth.com: How do clinicians deal with this?
Dr. Minkoff: This is the essence of "you form a relationship" and you use principles of motivational enhancement and motivational interviewing to steadily work with people toward improved adherence. Non-compliance is normal. It is not something that they are doing to us. Rather, it is part of their continuing decision making process about what makes sense for them.
The clinician must explore with people how to make better decisions about continuing treatment.
Page last modified or reviewed on March 8, 2009
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