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Behavioral Treatment for Substance
Abuse in People with Serious and
Persistent Mental Illness
Behavioral Treatment for Substance
Abuse in People with Serious and
Persistent Mental Illness

A Handbook for Mental Health Professionals

Alan S. Bellack  Melanie E. Bennett  Jean S. Gearon

New York London

Routledge is an imprint of the

Taylor & Francis Group, an informa business
Routledge Routledge
Taylor & Francis Group Taylor & Francis Group
270 Madison Avenue 2 Park Square
New York, NY 10016 Milton Park, Abingdon
Oxon OX14 4RN
© 2007 by Taylor & Francis Group, LLC
Routledge is an imprint of Taylor & Francis Group, an Informa business

Printed in the United States of America on acid-free paper

10 9 8 7 6 5 4 3 2 1

International Standard Book Number-10: 0-415-95283-2 (Softcover)

International Standard Book Number-13: 978-0-415-95283-5 (Softcover)

No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or
hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission
from the publishers.

Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation with-
out intent to infringe.

Library of Congress Cataloging-in-Publication Data

Bellack, Alan S.
Behavioral treatment for substance abuse in people with serious and persistent mental illness : a handbook for mental health
professionals / Alan S. Bellack, Melanie E. Bennett, Jean S. Gearon.
p. ; cm.
Includes bibliographical references.
ISBN 0-415-95283-2 (pb : alk. paper)
1. Drug abuse--Treatment. 2. Behavior modification. 3. Mental illness--Patients--Medical care. I. Bennett, Melanie E. II. Gearon,
Jean S. III. Title.
[DNLM: 1. Substance-Related Disorders--therapy. 2. Behavior Therapy--methods. 3. Mental Disorders--complications. 4.
Schizophrenia--complications. 5. Substance-Related Disorders--complications. WM 270 B4356b 2007]

RC563.2.B45 2007
616.86’06--dc22 2006014121

Visit the Taylor & Francis Web site at

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and the Routledge Web site at
http://www.routledgementalhealth.com
ASB: To Sonia McQuarters, who blossomed professionally with this project and who kept the
machine running through thick and thin. It would not have been possible without her.

MEB: To Stephen and Sondra Bennett for their help and support.

JSG: To Matthew, Vicky, and my brother Don for all their strength and courage.
 CONTENTS

PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Part I
1 INTRODUCTION TO TREATING PEOPLE WITH DUAL DISORDERS . . . . . . . . . . . . . . 3
2 SCIENTIFIC BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3 TRAINING PHILOSOPHY AND GENERAL STRATEGIES . . . . . . . . . . . . . . . . . . . . . . . . . 25
4 SOCIAL SKILLS TRAINING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
5 ASSESSMENT STRATEGIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Part II
6 MOTIVATIONAL INTERVIEWING IN PEOPLE WITH SPMI . . . . . . . . . . . . . . . . . . . . . . 65
7 URINALYSIS CONTINGENCY AND GOAL SETTING . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
8 SOCIAL SKILLS AND DRUG REFUSAL SKILLS TRAINING . . . . . . . . . . . . . . . . . . . . . . . 95
9 EDUCATION AND COPING SKILLS TRAINING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
10 RELAPSE PREVENTION AND PROBLEM SOLVING . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
11 GRADUATION AND TERMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223

Part III
12 DEALING WITH COMMON PROBLEM SITUATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
13 IMPLEMENTING BTSAS IN CLINICAL SETTINGS: STRATEGIES AND
POTENTIAL MODIFICATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

vii
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 PREFACE

The seeds of this book were planted in Philadelphia in the early 1990s. ASB and colleagues had been
conducting clinical trials and psychopathology studies at Medical College of Pennsylvania (MCP) with
people who had schizophrenia. As was standard practice at the time, we excluded people from our
studies who had comorbid drug abuse. It was assumed that they were behaviorally difficult to engage,
and that they had a different, more severe disease course with greater cognitive impairment. MCP was
located in central Philadelphia and, during the late 1980s and early 1990s, drug abuse, especially abuse
of crack cocaine, was an epidemic in the area. This tragic circumstance increasingly affected people
with schizophrenia, and over time more and more patients were being excluded from our studies due
to drug abuse. Kim Mueser, PhD, a colleague at MCP, recognized the significance of this problem and
was lead author on an early, seminal paper that identified the magnitude and possible causes of this
problem (Mueser, Yarnold, & Bellack, 1992), and a subsequent paper that discussed the implications
for treatment (Mueser, Bellack, & Blanchard, 1992). In examining the literature it quickly became ap-
parent that there was no empirically sound treatment available for people with dual disorders and we
began conceptualizing what an effective treatment might entail. A fortuitous circumstance about the
same time was that the National Institute of Drug Abuse (NIDA) issued an innovative program an-
nouncement for treatment development grants. Most NIH funding mechanisms at the time required
extensive pilot data, which required the availability of local resources. In contrast, this mechanism was
designed to provide pilot costs for investigators interested in developing new treatments: essentially
venture capital. ASB and MB submitted an application and were funded to develop an innovative
program that we called Behavioral Treatment for Substance Abuse in Schizophrenia (BTSAS). Shortly
after the grant was funded, MEB moved to New Mexico, and ASB moved to Baltimore, where he hired
JSG to help run the project. Preliminary data were sufficiently promising that we received funding for
a competitive renewal in 1998. To our great good fortune MEB moved to Maryland at about the same
time, and she rejoined our team.
This book is the culmination of 10 years of work. It evolved gradually as we learned more about
how to conduct the treatment. We dropped some elements that did not work as planned or were not
relevant to our subjects. Similarly, we refined many elements and added others. In many respects the
consumers who volunteered for our studies were our tutors. However, the changes have primarily been
evolutionary rather than revolutionary. The content of the current program is very similar to what we
initially proposed, although it is much more clinically sophisticated. In the course of conducting our
studies we also expanded the treatment beyond schizophrenia to include other consumers with serious
mental illness; hence, the current title: Behavioral Treatment for Substance Abuse by People with Serious
and Persistent Mental Illness: A Handbook for Mental Health Professionals.

ix
 As indicated by the second part of the title (A Handbook for Mental Health Professionals), the book is
designed to be a practical guide, not a didactic overview of dual disorders and their treatment. It contains
skill sheets that provide detailed lesson plans, and extensive examples of the specific language to be used
by clinicians. It also discusses problems that frequently arise and issues involved in implementing treat-
ments in public mental health clinics. It is our intent that a clinician who has some experience working
with dual disordered clients can read the text and actually do the treatment, not simply understand
how it is done by experts. There is a significant lag in our field between research on evidence-based
practices and application of these practices on the front lines. Behavior Treatment for Substance Abuse
has an evidence base, and we hope this book will provide enough clinical guidance that the evidence
can be effectively disseminated.
The text is divided into three sections. Part I contains five chapters that provide a background for
the approach and describes some general clinical parameters of the intervention: chapter 1 provides an
introduction to the treatment of people with dual disorders; chapter 2 gives an overview of the scientific
background; chapter 3 describes training philosophy and general strategies; chapter 4 discusses social
skills training, and chapter 5 discusses assessment strategies.
Part II contains six detailed chapters that cover each component of BTSAS: chapter 6 discusses
motivational interviewing; chapter 7 looks at urinalysis and goal setting; chapter 8 discusses social skills
and drug refusal skills training; chapter 9 considers education and coping skills training; chapter 10
discusses relapse prevention and problem solving; and chapter 11 covers graduation and termination.
Part III includes two chapters that deal with a number of ancillary topics that are important for
some clients and some settings; chapter 12 discusses dealing with problem situations, and chapter 13
discusses implementing BTSAS for substance abuse in clinic settings, along with strategies and potential
modifications.
There is also an Appendix that contains handouts for participants. The handouts duplicate materi-
als presented by group leaders during group sessions. They are given to participants when new mate-
rial is introduced so they can follow along during group, as well as take the material home to serve as
reminders.
We are indebted to the large group of clinicians who worked on the project over the years, without
whom the background research and manual development would have been impossible. We are also
indebted to the consumers who graciously volunteered to be research subjects in our studies.

Alan S. Bellack
Annapolis, MD
Melanie E. Bennett
Clarksville, MD
Jean S. Gearon
Washington, DC

x Preface
Part I
 Chapter 1
INTRODUCTION TO TREATING
PEOPLE WITH DUAL DISORDERS

D
rug and alcohol abuse by people with severe and persistent mental illness (SPMI) is one of
the most significant problems facing the public mental health system. Referred to variously as
people with dual disorders or dual diagnosis, mentally ill chemical abusers, and individuals
with co-occurring psychiatric and substance disorders, these patients pose major problems
for themselves, their families, clinicians, and the mental health system. Lifetime prevalence of substance
abuse was assessed at 48% for schizophrenia and 56% for bipolar disorder in the Epidemiological Catch-
ment Area study (Regier et al., 1990), and estimates of current abuse for the SPMI population range
as high as 65% (Mueser, Bennett, & Kushner, 1995). Rates of abuse are likely to be even higher among
impoverished patients living in inner city areas where drug use is widespread. Substance use disorders
(SUDs) in people with SPMI begins early in the course of illness, and has a profound impact on almost
every area of the person’s functioning and clinical care. People with SPMI and SUDs show more se-
vere symptoms of mental illness, more frequent hospitalizations, more frequent relapses, and a poorer
course of illness than do those with a single diagnosis. They also have higher rates of violence, suicide,
and homelessness. They manifest higher rates of incarceration, greater rates of service utilization and
cost of health care, poorer treatment adherence, and treatment outcome. People with schizophrenia
are now one of the highest risk groups for HIV, and there are ample data to indicate that substance use
substantially increases the likelihood of unsafe sex practices (Carey, Carey, & Kalichman, 1997), the
primary source of infection in this population. Women with schizophrenia and comorbid substance
use disorders are at substantial risk of being raped and physically abused (Gearon, Kaltman, Brown, &
Bellack, 2003). Substance use also impairs information processing, which is particularly problematic
for people with schizophrenia, given the range of cognitive deficits characterizing the disorder (Tracy,
Josiassen, & Bellack, 1995).
The toxic effects of psychoactive substances in individuals with schizophrenia and bipolar disorder
may be present even at levels of use that may not be problematic in the general population. Although
people with SPMI may abuse lower quantities of drugs, they are more likely to experience negative ef-
fects as a result of even moderate use. There is evidence to suggest that they are more sensitive to lower
doses of drugs (supersensitivity model). For example, in challenge studies, patients with schizophrenia

3
have been shown to be highly sensitive to low doses of amphetamine that produce minimal response
in controls (Lieberman, Kane, & Alvir, 1987). Other studies have shown that people with SPMI can
experience negative clinical effects, such as relapse, following self-administered use of small quantities
of alcohol or drugs (Mueser, Drake, & Wallach, 1998).
Why do people with SPMI use street drugs if the consequences are so severe? It is widely assumed
that they use substances as a form of self-medication: to reduce symptoms of mental illness and to al-
leviate side effects of medications, especially the sedating effects of many neuroleptics. However, the
data suggest that substance abuse by many people with SPMI is motivated by the same factors that drive
excessive use of harmful substances in less impaired populations: negative affective states, interpersonal
conflict, and social pressures. Empirical data do not document a consistent relationship between sub-
stance use and specific forms of symptomatology. Alcohol is the most commonly abused substance by
people with SPMI, as well as in the general population. Preference for street drugs varies over time and
as a function of the demographic characteristics of the sample. For example, Mueser, Yarnold, and Bel-
lack (1992) reported that between 1983 and 1986 cannabis was the most commonly abused illicit drug
among people with schizophrenia, whereas between 1986 and 1990 cocaine became the most popular
drug, a change in pattern similar to that in the general population. For many people with SPMI, avail-
ability of substances appears to be more relevant than the specific neurological effects. Poly-drug abuse
is also common, with availability determining which drugs are used when.
In addition, the pattern of use appears to be somewhat intermittent or adventitious, rather than
a persistent daily activity. For example, in our research, carefully diagnosed subjects meeting DSM-
IV criteria for drug dependence reported using drugs on about nine days each month, primarily on
weekends and when they received their benefit checks (American Psychiatric Association, 1994). Many
dual disordered people also seem to be able to go for periods of time (weeks or months) with little or
no drug use, and then resume regular use. Relatively few of these individuals fit the profile of the daily
(or almost daily) cocaine or heroin abuser, whose daily activity is focused on how to get money and
access drugs. Given this pattern of intermittent drug use, people with dual disorders generally do not
report extreme cravings or withdrawal symptoms. Rather, they seem to be very much affected by social
and environmental cues, especially including people with whom they often use drugs, and time (e.g.,
the week before benefit checks arrive). It is also worth noting that many people with SPMI do not have
enough money to maintain an expensive drug habit. They often access drugs from friends and family.
Some dually disordered women exchange sex for drugs, but it appears as if they are more likely to be
taken advantage of than to be active sex workers.

TREATMENT OF SUBSTANCE ABUSE IN PEOPLE WITH SPMI

There is extensive literature on the treatment of dual disordered SPMI patients (Bellack & Gearon, 1998;
Drake, Mueser, Brunette, & McHugo, 2004), and there is a broad consensus on a number of elements
required for effective treatment, including: There should be integration of both psychiatric and sub-
stance abuse treatment (Mueser, Noordsy, Drake, & Fox, 2003). The traditional service models in which
substance abuse and psychiatric (mental health) treatment are implemented by distinct clinical teams
with different funding streams does not work for these very impaired individuals. They are unable to
coordinate services between two distinct clinical systems, and they need a consistent message from all
relevant clinicians: drug use is harmful. We will discuss some models of integrated care in chapter 13).
Treatment should be conceptualized as an ongoing process in which motivation to reduce substance
use waxes and wanes (Bellack & DiClemente, 1999). BTSAS is designed to be a six-month program
because the literature suggests that this is a reasonable minimum time frame. However, that duration
was partly determined by the exigencies of our NIH grants; a longer duration will often be desirable or

4 Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness
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