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Treatment for concurrent disorders includes psychosocial treatments (discussed in this chapter) and medication (discussed in Chapter 8). Clients may receive one or the other, or both.

Types of therapy

Individual therapy allows the therapist to focus his or her attention solely on the client, with no distraction from others. Individual therapy is especially helpful in developing a close working relationship, exploring personal motivation and goals, and identifying individualized targets for intervention.

Group therapy (groups led by professionals) approaches offer the advantage of promoting social support among clients and providing positive role models for clients at earlier stages of treatment. Groups usually consist of up to 10 people. Often two therapists run them. A group setting can be a comfortable place to discuss issues such as family relationships, medication side-effects and relapses.

Psychoeducation

Psychoeducation is education about mental health and substance use issues. People who know about their problems are better prepared to make informed choices. Knowledge can help clients and their families deal with their problems, make plans to prevent future problems and build a plan to support recovery.

Everyone should receive psychoeducation when they begin treatment for concurrent disorders. Some people may have trouble processing or remembering information that they receive at this early stage. As they move through recovery, they may benefit more from psychoeducation. For people who have milder problems, psychoeducation alone may be the only treatment they need.

Psychoeducation sessions include discussions about:

• what causes substance use and mental health problems
• how the problems might be treated
• how to self-manage the problems (if possible)
• how to prevent future episodes.

Psychotherapy

Psychotherapy is sometimes called “talk therapy.” It helps people deal with their problems by looking at how they think, act and interact with others.

Certain types of psychotherapy are better for certain problems. Psychotherapy can be either short-term or long-term.

Short-term therapy has a specific focus and structure. The therapist is active and directs the process. This type of treatment usually lasts no longer than 10 to 20 sessions.

In long-term therapy, the therapist is generally less active, and the process is less structured. The treatment usually lasts at least one year. The aim is to help the client work through deep psychological issues.

Successful therapy depends on a supportive, comfortable relationship with a trusted therapist. The therapist can be a doctor, social worker, psychologist or other professional. Therapists may work in hospitals, clinics and/or private practice. There are many different types of psychotherapy.

Cognitive-Behavioural Therapy

Cognitive-behavioural therapy (CBT) is based on the theory that thoughts have an important influence on how people behave. Therapists help people to identify unhelpful thoughts and behaviours and learn healthier skills and habits. The client and therapist identify goals and strategies. There is an emphasis on practising the skills between sessions (homework).

Social Skills Training

Social skills training uses techniques such as role-playing, modelling, coaching, homework and feedback to help people learn (or relearn) interpersonal skills and competencies.

Dialectical Behaviour Therapy (DBT)

Dialectical behaviour therapy (DBT) is a type of cognitive-behavioural therapy. It is used to treat a range of behaviour problems. In DBT, people look at how their background and their life experience affect how they control their emotions. DBT draws on western cognitive-behavioural techniques and eastern Zen philosophies. It teaches clients how to:

• become more aware of their thoughts and actions (“mindfulness”)
• tolerate distress
• manage their emotions
• get better at communicating with others
• improve their relationships with other people.

Structured Relapse Prevention

Structured Relapse Prevention (SRP) uses a cognitive-behavioural approach to help people with moderate to severe problems gain more control over their use of alcohol and other drugs.

Psychodynamic (or Insight-Oriented) Therapy

Psychodynamic psychotherapy, also referred to as insight-oriented therapy, is based on the theory that unconscious processes (issues that a person may not be aware of) influence behaviour. This approach helps people examine unresolved issues that have resulted from relationship problems in their past.

Interpersonal Therapy

Interpersonal therapies help clients get better at communicating and interacting with others. These therapies help people:

• look at how they interact with others
• identify issues and problems in relationships
• explore ways to make changes.

Interpersonal group therapy focuses on the interactions among group members.

Motivational Interviewing

Motivational Interviewing (MI) is a method of enhancing a client's own motivation to change. MI was originally developed as a way of working with people with alcohol and other substance use problems. The approach is now used with people who have problems such as bulimia, hypertension, diabetes and concurrent disorders.

Peer support groups

A peer support group is made up of people who all have similar problems. Group members can share their struggles in a safe, supportive environment. People who have recently been diagnosed with concurrent disorders can benefit from hearing about the experiences of others. Group members usually develop strong bonds.

There are peer support groups for clients and for families. Double Trouble groups and Dual Recovery Anonymous are examples of groups for clients. The Family Association for Mental Health Everywhere (FAME) has groups for families. Although these groups are often called self-help, peer support actually offers a type of help called mutual aid.

Tips for evaluating peer support groups

Most family self-help / mutual aid organizations are geared toward either mental health issues (e.g., Mood Disorders Association of Ontario or the Schizophrenia Society of Ontario) or substance use issues (e.g., Al-Anon). However, many family members of people with concurrent disorders have found either or both of these types of organizations and groups to be extremely helpful.

If you decide to attend one of these groups, it is a good idea to evaluate them to decide if the particular group suits you and your situation.

Questions to ask about a self-help group

• Does this group welcome new members?
• Do group members respect each other?
• Is the group relevant to my situation, concerns and needs?
• Are there any requirements for attending this group (e.g., a membership fee)?
• Is the group respectful and inclusive of family members from diverse backgrounds (e.g., from a range of cultural, racial, religious and economic backgrounds)?
• Does the group offer both support and education?
• Is the group ongoing or is it time-limited?
• Does the group have a positive attitude toward professional help for families?
• Who facilitates the group and how is the group process managed?

If this group is for family members of persons with mental health problems:

• Is it OK to discuss my relative's substance use problems?

Is the group willing to consider harm reduction as an option in substance use treatment? If this group is for family members of persons with substance use problems:

• Is it OK to discuss my relative's mental health problems?
• Does the group support using medication to treat mental health problems?

Therapy for family members

Family members can also enter care as clients themselves.

Family therapy can offer advice and support to family members and teach them:

• about concurrent disorders
• how to help the client and support treatment efforts
• how to care for themselves.

Usually, therapists work with one family at a time. However, sometimes, family therapy is offered in a group setting with other families in similar situations. Group members can share feelings and experiences with other families who understand and support them.

Family interventions take advantage of clients' natural support systems and can lead to the creation of a home/family environment that is supportive of decreased substance use and adherence to an overall treatment program for the mental health problem.

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