SRP for Clients with CD - Adapting the SRP Approach - Introduction

Excerpted from Structured Relapse Prevention: An Outpatient Counselling Approach.

• Adapting the SRP Approach
  • Introduction
  • Screening and Assessment
  • Treatment
  • Other Issues of CD-Adapted SRP
  • References
• PDF version of Adapting the SRP Approach

Marilyn Herie, Andrea Tsanos and Lyn Watkin Merek

Client Profile: Steve

Steve is 32. He has a diagnosis of schizophrenia and is connected to the outpatient mental health program. He has a psychiatrist and a case manager, and medication is part of his treatment plan. Steve uses crack cocaine, typically in binges, particularly when his monthly disability cheque arrives. He also smokes marijuana and drinks alcohol. His substance use has had negative consequences for his mental health (it has produced psychotic symptoms), and also may jeopardize his housing situation (since substance use is not tolerated in the supportive housing where he lives). Steve calls crack “the Devil’s drug,” but feels he is hooked, and still values the escape and social enjoyment he gets from it. He says it is difficult for him to resist when drugs are offered to him, and he finds it hard to be assertive in refusing drugs if he is approached by dealers in his neighbourhood and has money in his pocket. He is open to receiving help to explore his use of crack, but does not see his marijuana and alcohol use as problematic.

This chapter addresses the issue of how we can work effectively with clients like Steve, who present with concurrent substance use and mental health issues. In what follows, we outline an adapted version of SRP for clients with concurrent disorders (CD). The first section of the chapter discusses the prevalence of concurrent disorders and summarizes some of the key research findings related to working with clients with concurrent disorders. It also includes some tips for running SRP groups with this population. The following sections provide session outlines and clinical tools that have been adapted for use with clients with concurrent disorders.

Over the past decade, there has been an increasing appreciation of the needs of people with concurrent mental health and substance use issues. A variety of studies seeking to establish the prevalence rate of concurrent disorders have shown that roughly half of individuals with either a mental health or substance use disorder had concurrent disorders at some point in their life (Health Canada, 2002; Kessler et al., 1996; Regier et al., 1990). In an Ontario study of clients seeking treatment for substance use problems, 68 per cent had a concurrent mental health disorder (Ross et al., 1995). As expected, the study indicates that the prevalence rates are higher in agency and hospital populations than in the general population. However, the rates in clinical populations varies considerably, depending on the setting and the method of diagnosis.

What is clear is that this traditionally underserved (even, often, ignored) population comprises a high proportion of clients presenting for service in either specialized substance use or mental health settings, as well as other contexts (such as hostels and shelters, criminal justice and corrections systems, child protection and family services, employee assistance programs and primary care settings). The increasing recognition of the high co-prevalence rates has led clinicians to screen routinely for the presence of concurrent disorders. Ignoring or not properly recognizing concurrent disorders can affect clients’ ability to recover successfully from both disorders, and negative effects can include:

• premature dropout from treatment
• higher risk of relapse
• risk of harmful interactions between drugs of abuse and psychiatric medications
• misinterpretation of symptoms (e.g., are they signs of a mental health problem, the effects of substance use or signs of withdrawal from substances?)
• likelihood of the client needing more expensive services in future.

However, a variety of factors, have made it difficult for agencies and health care organizations to respond adequately to the needs of people with concurrent disorders: lack of specialist knowledge and skills in substance use, mental health or both; limited access to specialist diagnostic and other treatment services and providers; agency exclusion criteria; problem complexity; and fragmented treatment systems. Nonetheless, people with concurrent disorders are often best served where they present; at the very least, they are best served within the context of an integrated treatment program or system (Health Canada, 2002).

Because research is still lacking in this area, our current understanding of best practices in screening, assessment and treatment of people with concurrent disorders must be seen as still in development. What we do have, though, is an emerging consensus regarding how best to design programs and systems to provide more seamless and integrated care, and how to respond clinically to clients with concurrent disorders. Integrated treatment for concurrent disorders started in the early 1980s as a solution to the difficulties and poor outcomes associated with “sequential” and “parallel” treatment systems that were not co-ordinated. Integrated treatment occurs when “mental health treatments and substance abuse treatments are brought together by the same clinicians/support workers, or team of clinicians/support workers, in the same program, to ensure that the individual receives a consistent explanation of illness/problems and a coherent prescription for treatment rather than a contradictory set of messages from different providers” (Health Canada, 2002, p. 15).

Minkoff (2001) has articulated the following key principles of integrated treatment for concurrent disorders:

• comprehensive programs and services designed to respond to the substance use, mental health and other issues with which clients present
• continuity of treatment over time, as many clients with concurrent disorders require long-term follow-up, aftercare and community support
• accessibility in the location of services; flexibility in hours and service delivery
• acceptance by practitioners of both mental health issues and substance use issues
• a sense of optimism about the possibility of recovery, even for clients with very severe or complex problems
• treatment that is tailored to individual needs
• culturally competent treatment.

The end result of a fully integrated approach is essentially a “no wrong door” response for individuals with concurrent disorders. Within this approach, new clients presenting to either a mental health or a substance use facility receive screening, assessment and treatment services both for substance use and for mental health problems.

Return to the index of excerpts from Structured Relapse Prevention: An Outpatient Counselling Approach.

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