Seminar Paper on "Dual Diagnosis Population"

Seminar Paper 5 pages (2112 words) Sources: 1+

[EXCERPT] . . . .

Population Needs and Assessment

Dual Diagnosis, Comorbidity, and Modified Therapeutic Communities

The term dual diagnosis is a term typically reserved for someone suffering from a mental disorder and a comorbid substance abuse problem, although technically the term comorbidity is more appropriate. There has been some debate in the literature surrounding the use of a single diagnostic label for a group of individuals who have a wide variety of different psychiatric diagnoses and different substance abuse issues (Evans & Sullivan, 2001). The term "comorbidity" was a term introduced in the medical field in the 1970s by an epidemiologist to describe the presence of more than one distinct different disease occurring in an individual at the same time (Feinstein, 1970). The designation of comorbid diseases assisted physicians to prioritize the treatment needs of these individuals and understand how the presence of one disease could increase the vulnerability to other conditions.

The terms dual diagnosis and comorbidity are popular the field of mental health as those diagnosed with psychiatric disorders often present with many diverse symptoms. However, symptoms like anxiety, depression, and issues like substance abuse are common manifestations of nearly all mental disorders have been observed to have comorbidities with many other psychological problems. The diagnosis of physical diseases occurs on the basis of objective medical test results, whereas the diagnosis of psychiatric disorders is done on the basis of subjective feelings, behavioral observations, and some conjecture. The term comorbidity was originally designed to denote the presence of separate but distinct identifiable disease conditions; a dual diagnosis implies a distinct group of such individuals (in terms of the way it is phrased; Maj, 2005). In reality, the use of the terms comorbidity or diagnosis for mental disorders may not reflect the presence of distinct multiple disorders, but may reflect the inadequacy of the DSM and the inability of the mental health field to apply a single diagnostic label for a psychiatric disorder that is comprised of many different symptoms (e.g., see Lilienfeld, Waldman, & Israel, 1994; Maj, 2005). Moreover, the diagnosing of several comorbid mental disorders in an individual often reflects a "symptom management" approach to diagnosis in clinical psychiatry and psychology as opposed to trying to understand the overall picture (Lilienfeld, et al., 1994).

Despite the issues with the use of such terms as "dual diagnosis" and "comorbidity" it has become clear that individuals with mental disorders and co-occurring substance abuse issues present special challenges. People given co-occurring diagnoses face a host of multifaceted challenges in treatment and other areas of their lives such as increased rates of relapse, re-hospitalization, homelessness, legal issues, and substance abuse related conditions such as Hepatitis C or HIV infection (Center for Co-Occurring Disorders, 2006).

Those individuals with legal issues and dual diagnoses often require special services and monitoring programs to help assist them from becoming habitual offenders as a result of mental health issues. Correctional institutions are challenged to prevent recidivism in this group. Nationwide the correctional system has turned to therapeutic community programs in treating offenders who have co-occurring mental and substance use disorders, a group that has a mounting prevalence in prison populations (Sullivan et al., 2007). Modified Therapeutic Communities (MTCs) are specially designed for the treatment of offenders who have both mental illness and substance abuse disorders. These programs modify therapeutic community models for substance users to apply them to legal offenders, both men and women of all ages, who present co-occurring disorders (Sacks et al., 2004). Data is collected via a review of records, diagnostic information obtained in the legal records and from physicians following clients and clinical interviews with clients suited for the program. The MTC formula is especially suited to treating this group.

Program Design

Interventions

The MTC formula is a modification of the conventional therapeutic community model that alters the original model in such a manner that is more suited for offenders who present with both substance abuse issues and mental illness. The major elements in the MTC program include both individual and group counseling, evaluations and monitoring of mental health issues, and medical management of both appropriate mental health issues and physical issues (Sacks et al., 2004). The MTC model conceptualizes recovery and treatment in four specific phases (e.g., see Sacks, Banks, McKendrick, & Sacks, 2008; Sacks et al., 2004; Sullivan et al., 2007):

(1). Admission to the program. Here offenders are oriented regarding what to expect while in the program.

(2). A primary treatment phase including counseling (group and individual), medication management, and assistance with other issues such as readjustment and reintegration.

(3). A live-in reentry into the community segment starting during incarceration or in a half-way house type situation upon release.

(4). A live-out reentry into the community transitional stage that allows members to continue treatment while they are out in the community for a specified time period.

Live-in aspects of the program are performed daily from the hours 8:00 AM to 8:00 PM. with a few breaks. Live-out aspects of the program are designed to work around the client's employment schedule, but also maintain a regular schedule of treatment. Programs are typically funded through the State and/or with Federal grants. In-house programs require medical staffing (psychiatrists, physicians, nurses), counselors trained in both the treatment of psychiatric disorders and substance abuse, and of course supervisors and security personal. Live-out programs require the client to be followed by a corrections (probation) officer, physician and/or psychiatrist, and a counselor.

Assessment

Areas of focus for the assessment of the program are targeted at: substance use, criminal behavior, psychological problems, employment issues (live-out phase), economic benefit to communities, and housing stability for clients.

Counselor Involvement

Counselors are urged to approach both chronic mental disorders and substance dependency as having elements of both shared and personalized manifestations. Both can fit into a model of recovery and treatment. The goal for the counselor is to help to stabilize acute symptoms and then to get the individual to accept and employ in a treatment program of long-term maintenance, rehabilitation and recovery. Counselors approach the dual diagnosis with the attitude that each diagnosis is considered to be primary and either diagnostic problem can exacerbate the symptoms of and interfere with the treatment of the other. The use of individual sessions helps to personalize the treatment and the use group sessions helps to address shared issues.

The phases of recovery for dual diagnosis patients are considered to follow an established format that begins with acute stabilization, progresses to engagement in treatment, then to prolonged stabilization/maintenance, and finally to rehabilitation/recovery (Minkoff, 1989). Osher and Kofoed (1989) in discussing the treatment of dual diagnoses expanded the engagement stage to allow counselors a format to focus on in the treatment of these individuals (these substages include engagement, persuasion, active treatment, and prolonged stabilization). The goal of the counselor is to help the client reach a period of prolonged stabilization and understanding of both their personal issues and the general issues of the particular conditions they face. Of course recovery depends a great deal on patient motivation, and motivation may vary from individual to individual. Counselors attempt to engage clients in active treatment in order to enhance motivation (Minkoff, 1989; Osher & Kofoed, 1989).

Special Issues

All clients have contact with counseling and psychiatric services which are provided by treating mental health professionals. As residents progress through each of the program stages and are able to show greater responsibility they are gradually allowed to take on greater independence in their lives. Supervision remains tight during all of the transitional periods and clients continue to meet regularly with their probation officers.

There is a movement to recognize that substance abuse/dependence often requires an approach focused on rehabilitation as opposed to incarceration (Leon, Sacks, Staines, & McKendrick, 2000; Sacks et al., 2004). Certainly advocacy groups for mental illness and substance abuse would be in favor of extending these MTC programs. There are going to be some issues with various the live -- out program sites as the communities may not want these programs in their specific area. But, several other MTC programs have been successful at finding adequate live -- out facilities for their clients (Sullivan et al., 2007).

Certain conservative groups may oppose the focus of treatment and rehabilitation for certain types of MTC clients; however, positive outcomes from research indicate that these programs are indeed effective. One of the major issues with MTC programs is providing a sufficient number of adequately trained counselors to follow these individuals through all phases of the program and to assist them (Sacks et al., 2004).

Evaluation

Typically MTC programs are evaluated at multiple times over the course of the program and with follow-up data at intervals upon completion. The initial data typically comes from legal record reviews, clinical data is a part of the client's records, structural interviews, and specific types of psychometric instruments such as the Beck Depression Inventory (Beck, Brown, & Steer, 1996) or other research -- focused assessment tools (Grella & Shi, 2011; Sullivan et al., 2007). Much of… READ MORE

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