Sequential Services

In sequential services a person with a dual diagnosis first receives treatment for one of the disorders. When the first disorder is successfully dealt with or "under control," the individual is referred for treatment for the subsequent disorder. This method has been found to be largely ineffective since the disorder that is not being treated often undermines the treatment for the disorder being addressed (Drake, Bartels, Teague, Noordsy, & Clark, 1993).

Traditionally, mental health treatment consists of psychotropic medication (Chapter 3), individual and or group counseling, perhaps day program services (Chapter 6), and case management services (Chapter 7), which are typically used for persons with severe and persistent mental illness. Traditional substance abuse treatment often requires abstinence (refraining from the use of all drugs), sometimes including abstinence from psychotropic medication, attendance at Alcoholics Anonymous (AA) or Narcotics Anonymous (NA) meetings, and working a 12-step process based on the AA 12-step model (Evans & Sullivan, 1990).

A popular misconception on the part of mental health providers has contributed to this method of treatment. Many providers believe that people with mental illness engage in substance use solely as an attempt to self-medicate. In other words, drugs or alcohol are used to provide relief from their psychiatric symptoms. If this is the case, it follows that adequate treatment of the psychiatric disorder would eliminate the need for the use of substances. This theory has not proven to be helpful for many people with dual disorders. Studies of motivation for using substances indicate that people with psychiatric disorders use substances for a variety of reasons other than relief from symptoms such as to feel relaxed, to improve social interactions, to be accepted by their peer group, and to alleviate boredom (Bellack & DiClemente, 1999; Nishith, Mueser, Srsic, & Beck, 1997; Spencer, Castle, & Michie, 2002). Not surprisingly, it appears that people with mental illness use substances for some of the same reasons as other substance abusers and users.

Treatment for the psychiatric disorder in the absence of treatment for the substance abuse is ineffective for both disorders. People engaged in substance abuse experience resulting impairments that interfere with their ability to engage in rehabilitative activities, manage a medication regimen, or even keep appointments with doctors and other treatment practitioners (Mueser et al., 2003a). It is not difficult to imagine the difficulty in monitoring the effect of a medication regimen, the most important agent for symptom control, at the same time someone is engaged in substance abuse. In addition, there is some evidence that substance abusers are more likely to lower or increase their prescribed psychotropic medications at their own discretion, compared to other individuals (Heyscue, Levin, & Merrick, 1998; Krystal, D'Souza, Madonick, & Petrakis, 1999).

Likewise, substance abuse treatment in the absence of mental health treatment is equally ineffective. Besides the obvious problem of untreated psychiatric symptoms, unad-dressed functional impairments related to the psychiatric illness will interfere with the ability to address the substance abuse issues.

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