EXTRACT FROM "THE COFFS HARBOUR MODEL"

Treatment Elements:

Outpatient follow-up and education concerning both mental illness and substance use-disorder was essential. Based on the literature the therapists selected  treatment elements supported by studies:

Using an outpatient group structure incorporating this raft of strategies has been shown to be generally effective, but most studies were uncontrolled with small samples (Kofoed et al., 1986; Hellerstein & Meehan, 1987; Noordsy & Fox, 1991; Drake, McHugo & Noordsy, 1993). Only three controlled outpatient group treatment outcome studies have been reported and they showed no improvements, however these trials had small samples, short trial times and problems obtaining regular and high attendance (Carey & Carey, 1990; Hellerstein, Rosenthal & Miner, 1995; Lehman et al., 1983). However a recent pilot study using an outpatient group treatment incorporating elements of psychoeducation, goal setting, relapse prevention, psychiatric support with low judgement from the group convenors, and tolerance of non-abstinence at least in the early part of treatment seems to have been effective. This was so even although the group ran only one hour per week for a year (Addington & el-Guebaly, 1998).

Group Design:

Unlike most of the overseas group treatments, the clinicians’ group was outpatient based only, focussing on patients with a serious mental illness and substance abuse disorder or problematic substance use condition. It was not time limited, but was to be ongoing, since it was considered that patients’ needs would be ongoing also, being burdened by two interacting, chronically relapsing disorders. The notion that recovery for dually disordered outpatients was a long-term process is supported in the literature (e. g. Carey, 1989; Drake, Teague & Warren, 1990; Carey, 1995; Clark et al., 1998).

The group was held weekly, and ran for one to one and a half hours and was co-convened by members of both relevant clinical specialties. Group members were identified and referred by all mental health and drug and alcohol clinicians in the Coffs Harbour area after subjects were solicited. In the first year of the group’s operation most referrals were of the most extreme cases, with the most obvious substance-abusing patients identified by referring clinicians. Some subjects came willingly, while others were under legal compulsion through Community Treatment Orders. The group was initially run in the outpatient unit of Coffs Harbour Base Hospital, but the group convenors changed the venue to the more informal and less clinically threatening environment of the ‘Living Skills’ centre which is a day activity house for all outpatients suffering a mental illness.

Engagement:

The difficulty of engaging dually disordered patients into treatment is well documented (e.g. Lehman et al., 1993). Engagement is even more difficult when the first step some dually disordered patients need is detoxification, and where such facilities are very hard to access, as they are in rural settings. Similarly, with psychiatric in-patient stays becoming generally shorter, and with inpatient beds at a premium, it is hard to take advantage of any windows of opportunity inpatient placement may present to clinicians. Thus, attempts to engage dually disordered patients when they are not inpatients long enough to do more than recover from their most recent psychiatric crisis poses further treatment difficulties.

Most patients attending the outpatient dual disorder treatment group are polydrug abusers; with cannabis and alcohol the two most commonly used substances. Attendance at any group can range from 4 – 16 patients, most commonly around eight. Non-attendance can be caused as much by transport difficulties, common to rural areas, as for any other reason.

All well-known specialist treatment programs for dually disordered populations described in the North American literature explicitly set the goal of abstinence for all patients for all non-prescribed and "recreational" substances (except nicotine and caffeine) as either the pre-condition for treatment, or the immediate and long-term goal of treatment.

The programs’ authors either state or imply that any substance use by people with a mental illness will produce symptom exacerbation, poor functioning and eventually, relapse. They assume that asymptomatic use is synonymous with abstinence, and that any substance use is associated with harm (e.g. Sciacca, 1991; Reilly, 1991; Galanter et al., 1994; Drake et al., 1998). However, there are those who argue that this position is not scientifically supported (Phillips, 1999). Also there are variations between the sensitivity of mentally ill persons to psychoactive substances with some patients evincing inductions or exacerbations of their psychiatric symptoms and relapses with minimal substance use (Drake, Osher & Wallace, 1989) while others appear to be able to tolerate moderate amounts without problems (Dixon et al., 1990).

Harm Minimisation:

This less sensitive group is not discussed in most of the treatment literature concerning dually disordered patients in any detail. This variation in sensitivity to the symptom response to substance use in this population suggests that setting substance use goals should be based on an empirical, flexible and individual basis to achieve substance use doses and patterns resulting in asymptomatic use rather than setting abstinence a priori as the only goal which will achieve asymptomatic use for all substances and for all patients.

Alternatives to abstinence-oriented programs are more likely to engage persons who do not see abstinence as a valid goal for treatment (Marlatt & Tapert, 1993).

Clinical observations (Levy & Mann, 1988) and empirical evidence (McHugo et al., 1995) supports the notion that few dually disordered patients seem willing to reduce substance use without clinical interventions, and some researchers in the United Kingdom have recommended that harm reduction goals rather than abstinence should be explored as a more pragmatic goal for this population (Phillips & Labrow, 2000). To demand abstinence from all substances, for all patients, as the only treatment goal would potentially alienate mentally ill persons who may have problems with some substances or combination of substances but not with all substances and is not supported (Phillips, 1999; Levy & Mann, 1988; McHugo et al., 1995).

The only treatment model in the literature which argues for allowing patients to continue substance use as a long-term goal does so on the grounds of harm minimization (Carey, 1996). Carey argues that more young people could be engaged into treatment, and reducing harm is better than setting abstinence as a goal which would result in certain dually disordered patients, notably young people, receiving no treatment.

Motivation:

Motivation  has been shown to be important to achieve positive outcomes for dually disordered patients (McHugo et al., 1995). It has been suggested that motivation to change can be increased by therapists integrating substance-abuse treatment with mental health treatment, and applying the five motivational levels of Prochaska, DiClemente and Norcross (1992). These stages consist of precontemplation, contemplation, preparation, active change and maintenance. This model is not inconsistent with the motivation-based stage-wise intervention models of Mueser & Noordsy (1996) which identifies the stages of engagement, active treatment and relapse prevention, and Osher & Kofoed’s (1989) model which indicates the stages of engagement, persuasion, active treatment and relapse prevention. The unifying themes through all these motivational models is that patients must be engaged with interventions that match patient needs and stage-of-change readiness, perceived by them as relevant, before the essential basis for treatment success can be established (Ziedonis & Trudeau, 1997).

Treatment Goals:

A distinguishing feature of our program is that goals are set purely in terms of the threshold levels of substance use that induces symptomatic responses; these are different for different patients.

Abstinence may  be the  goal decided on empirically for certain substances for a particular patient. Abstinence for all substances may be the goal for someone else if previously controlled substance use become problematic.

This empirical approach to the setting of the substance-use goals of treatment is consistent with the essence of harm reduction principles where the primary goal is the reduction of harm without  seeking to reduce substance use unnecessarily per se (Heather, 1995). Evaluation of treatment programs utilizing harm reduction goals should be able to demonstrate actual, measurable reductions in designated substance-related harms to the substance user and the community (Heather, 1995; Single, 1995; Lenton & Midford, 1996; Single, 1997).

In the current study the harms being targeted for reduction are:

Social Setting:

The lack of social outlets in rural areas, in conjunction with the limited social confidence and skills of dually disordered outpatients means that setting treatment goals of alcohol and cannabis abstinence could severely limit patients’ already limited social contacts in the community. This fact has been noted, especially in younger dually disordered people in North America, where they reported substance use was encouraged by their peers and motivation for use further partly explained as a way of avoiding the social isolation complained of by young mentally ill persons in the community (Cohen & Klein, 1970; Bergman & Harris, 1985).

Peer pressure and the desire to avoid social isolation are also probable factors motivating the drug use behaviours of Australian mentally ill persons, especially the young. Indeed, large subcultures within the Coffs Harbour community assume that alcohol and cannabis use is a natural adjunct to any friendly social intercourse. This view seems to be accepted by large numbers of the general Australian public as much as by our target population where alcohol and cannabis are the most often used substances in the general community (Hancock et al., 1992; Australian Institute of Health and Welfare, 1999).

The treatment goals of the Coffs Harbour dual disorder group do not assume that abstinence should be an initial or even eventual goal or outcome of treatment. Instead, priority goals for each patient are set to reduce substance consumption levels until they no longer induce or exacerbate psychosocial symptoms.

The drug causing the most harm at the time they come into group treatment is the one focussed on initially to be reduced to asymptomatic levels of consumption, and after this has been achieved the other lesser problematic substances used are targeted. Reducing substances consumed to asymptomatic dosages may well equate to total abstinence for some or even all substances for some patients. However each group member is individually assessed to find the asymptomatic threshold for each drug they use, and to engage the patient to confront the past consequences of breaches to these thresholds. The aim is to get them to ‘contemplate’ (Prochaska & DiClemente, 1986) whether it would be wise to continue dosage levels of the past into the future. The strategy used in the treatment group to achieve these outcomes is further described below .

The treatment objective of the outpatient group is to maximize the levels of functioning of the dually disordered members by lowering relapse rates in both disorders. These patients, especially those suffering schizophrenia, have difficulty accepting their disorders due in part to varying degrees of residual impairment of cognitive functioning, resulting from the nature of their disorder even when symptoms are optimally controlled. The function of the group treatment is to assist patients make informed and considered choices and to understand more about their mental and substance use disorders.

Group interaction is often very effective without the need for the convenors’ input. The group process can persuade members to accept that each individual has a substance abuse problem, as well as accepting they have a concomitant serious mental illness and must accept responsibility for these conditions and accept treatment accordingly. Group members frequently show evidence of the knack of gentle but effective confrontation by offering fellow members their own personal history as evidence of the consequences of denying their dual disorders.

The first step of group treatment is to engage new members   the process of acceptance that they have two chronic interacting disorders. New members are asked if they have a mental illness and if they have any problems with alcohol or other drugs. Any discrepancies between the group convenors’ knowledge of the new member’s medical history and their self-perceptions are gently challenged and they are encouraged to identify their problems and share them with the group. In this way questions assessing the level of acceptance that a group member has of his or her two disorders are at once an ongoing assessment process and a therapeutic intervention since the same questions will be asked in different ways every group session. Other researchers have called this approach "careful confrontation" (Nikkel & Coiner, 1991).

This gentle approach is recommended, since a more direct confrontational approach may result in a psychological resistance called reactance, where oppositional behaviour is evoked when individuals perceive they are being strongly influenced (Brehm & Brehm, 1981). Open-ended questions and reflective listening   from group convenors are likely to elicit pertinent responses from group members (Miller & Rollnick, 1991).

Eliciting information concerning consequences of substance abuse is a therapeutic intervention in itself since the questioning process encourages each group member to reflect on their substance use and its consequences and the resultant symptoms. It has been shown that when dually disordered people relate negative social outcomes to substance use that they become more ready to change their substance using habits (Blume & Marlatt, 2000). In this way the assessment process serves to educate and gently challenge the group members into new awareness’s leading to change.

Other researchers also see assessment as a treatment intervention (Drake & Mercer-McFadden, 1995). It has been argued that assessment with this population should be ongoing and interactive with treatment planning and treatment (Drake & Mercer-McFadden, 1995). With successful treatment a group member’s psychiatric presentation is likely to change, and with successful intervention rapport and trust has developed allowing more accurate reports of substance use patterns. Therefore psychiatric symptoms and diagnoses, as well as treatments, should be continually reassessed and assessments taken over short time intervals (Kofoed, 1991; Skinner, 1984; Harrell, 1985).

Education, information and responsibility are offered group members concerning the nature and treatments recommended for their conditions so that they can achieve the highest possible level of psychosocial functioning with their dual disorders. They are given explanations of the way prescribed and recreational drugs affect their mental state, why they need to be careful with their drug use, the negative interactions between prescribed and recreational drugs and the possibility of exacerbation of their psychiatric symptoms.

Each group member is encouraged to identify each drug used and the dosage at which psychiatric symptoms and negative social and legal consequences have been found to onset. This is a process worked on many times in the group, often over months, as the clinicians as well as the group members discover what substances, in what dosages, and in what contexts, are known to produce negative symptoms and consequences in each particular group member. These are always consequences that group members do not wish to repeat, even if they are not clear how their substance use patterns have contributed to these consequences. The group focus constantly encourages group members to identify drug potencies, settings and situations and plan ahead to stay within asymptomatic use levels by specifying specific drug dosages and interactions at which they should cease consumption. Specific, personalized strategies to achieve and maintain this outcome are offered by the group’s convenors and fellow group members.

Strategies to avoid psychiatric relapses from substance abuse and from other behaviours and stressful situations are indicated and reinforced for individual group members in specific instances. Guidelines for substance abuse relapse prevention approaches, not specifically developed for mentally ill sufferers, (Marlatt & Gordon, 1985) have been used with good effect in our dual disorder groups. In this way behavioral rehearsal of effective prevention strategies tailored to each group member is achieved and reinforced both by successes and relapses for each group member when they are reported to the group. Attention is given to both disorders and their interactions and how to avoid these harmful and unpleasant outcomes for each member in the group.

A group is a cost-effective treatment vehicle, needing a low clinician-to-patient ratio. It allows vicarious learning, modeling, peer support and is, in itself, a social experience that appears to be of pleasure and value to the participants.

It appears to be less threatening and less discomfortingly intense for individuals with mental illnesses to be gently challenged in the group than if this was to be done in an individual one-to-one session. The focus of attention appears to be felt as less intense than in an individual therapy session. When discomfort or resistance is encountered with a particular dual disorder patient in the group, it is easy to shift the focus away to another more ‘open’ patient to tell their story about the same problem. In this way the group process seems able to allow titration of the intensity and stage of intervention for patients at difficult points in the treatment process and defuse the counterproductive anxiety or denial that might otherwise have resulted, but without leaving the therapeutic issue at hand.

The group process allows the resisting patient to be kept engaged, and involved with the particular issue, by the convenors being able to shift the focus on this particular issue, from the individual to the group. The point to be taught is held, but the focus changes from one of a personal confrontation between therapist and resisting patient, to one of utilizing the group to address the same issues but through the learning modalities of identification, vicarious learning and modeling from the experiences, lessons and insights volunteered or elicited of a fellow patient’s experiences.

Of course, the group also has disadvantages in that different patients are at different levels of awareness of their dual disorders, and are at different stages of change (Prochaska & DiClemente, 1986) in the treatment process. However the group convenors’ role is to turn all material presented in the group back towards the primary group goal of getting group members to identify those elements and patterns of their substance use and non-substance use behaviours which have been found to be risk factors in producing relapses for them in the past, and how they might avoid such situations arising in the future. The group, as a therapeutic context, seems to offer far more advantages than disadvantages, and disadvantages can frequently be neutralized or turned into an advantage by the creative responses of the group convenors.

It has been shown that people with serious mental illnesses respond poorly to strong confrontation in any context, therapeutic or social (Koenigsberg & Hadley, 1986; Mintz et al., 1987; Kavanagh, 1992). They respond well to a relaxed personal leadership style where humour and non-moralistic attitudes prevail. The group treatment approach is a flexible and adaptive format allowing the group’s leaders to keep up interest and involvement. Due to the low attention span of some mentally ill patients, the group leaders allow group members to walk in and out of the group while it is in progress if they feel the need. Informational content is kept simple, brief and concrete with conclusions and behavioural suggestions spelt out clearly for the same reason. An informal leadership manner is indicated. Punctuality and reliability in attendance by the group leaders creates confidence in the attending patients that the group will always be going on time, and this seems to foster their regular attendance.

The co-convenors take responsibility for the running of the group. They do not initiate or allow strong confrontations between members to occur since people with serious mental illnesses do not profit from such challenges (Mintz et al., 1987; Koenigsberg & Hadley, 1986). Disruptive patients are screened out until their mental functioning is controlled enough for them to benefit from group participation. Patients are not allowed to have 'drug raves’ in group time. Such attempts are quickly redirected to the resultant consequences experienced to the 'drug raver' from their last symptomatic drug use episode by the co-convenors. In this way the consequences of exceeding asymptomatic drug use thresholds are reinforced, preferably humorously and without moralizing, to maximize the therapeutic and heuristic impact while softening the confrontational aspects of the intervention for the recipient.

The early effects of the running of this group were that both clinicians discovered the similarities and benefited from the differences between their respective professional training and experience. The setting up of a special group inadvertently focussed other mental health workers’ attention to patients with dual problems. Unsolicited referrals to the group began to increase. Both clinicians developed a better understanding of the unique interacting features of the dual disorder dynamics as they applied to each patient from seeing them in the dynamic context of an informal group rather than in the more static one-to-one formal clinical setting of individual counselling.