Diagnosis of Mental Health Issues and Alcohol or Drug Misuse - Essay Example

A Critical Examination of Assessment and Interventions for Client Groups Presenting with a Dual Diagnosis of Mental Health Issues and Alcohol or DrugMisuse Introduction In recent years, it has become increasingly apparent that many individuals diagnosed with psychological disorders or illnesses are also afflicted with problems arising from substance abuse (Drake & Wallach, 2000; Brems et al., 2006). These combined substance abuse mental health issues complicate clinical diagnosis and therapeutic regimens. The term “co-occurring substance use and mental health problems” has been defined to address the fact that mental health issues and substance use are often seen in the same client and must be considered in regard to the extent to which these co-occurring situations may contribute to ongoing psychological issues requiring treatment intervention. The slightly modified term “co-occurring substance misuse and mental health problems” refers more specifically to the observation that these co-occurring substance use and mental issues are frequently associated with the misuse of drugs and alcohol in ways that may complicate and contribute to psychological illness. In this context, the term “substance misuse” refers to the use of illegal drugs, the illicit use of prescription drugs and/or the excessive use of alcohol. When substance misuse and mental health problems co-occur in the same individual, this is termed a “dual diagnosis” or “co-morbidity”, although it should be noted that these two terms may apply more generally to any two conditions existing simultaneously in the same individual. The increased awareness of the co-existence of mental health and substance abuse issues in clients seeking or requiring psychological treatment represents an acknowledgement that mental health issues may have complex, multi-faceted origins that require individualized approaches to treatment and recovery (Drake & Wallach, 2000). It has also drawn attention that many individuals who are substance abusers are not simply guilty of criminal or excessive behaviours, but may abuse drugs or alcohol in the context of undiagnosed or untreated mental illness (Brems et al., 2006). The purpose of this essay is to explore some of the current assessment and therapeutic approaches to the treatment of clients presenting with this type of dual diagnosis, including cognitive behavioural therapy (CBT), motivational interviewing (MI), and brief interventions. Cognitive behavioural therapy is a therapeutic approach that is based on the premise that psychological issues are the product of aberrant thought processes and associated behaviours (Mueser et al., 2005). The goal of this approach is to produce changes in thinking and behaviour that are the causes of the individual’s symptoms. Motivational Interviewing is a therapeutic approach originally developed for the treatment of substance misuse that involves a guided discussion of relevant issues with the client in a respectful, collaborative approach designed to engage the client as an active participant in the recovery process (Mueser et al, 2005). Brief Interventions are defined as short-term therapeutic approaches that frequently involve motivational interviewing techniques. The concept of brief intervention was developed originally to combat alcohol abuse and involved very short-term sessions (Mueser et al, 2005). The scope of brief interventions has expanded both in regard to the component therapeutic strategies employed and the overall length of the “brief” intervention, depending on the therapeutic application. Each of these therapeutic modalities will be critically analysed as they are applied to the treatment of individuals whose co-morbidities are comprised of ongoing substance misuse and mental health problems. These psychosocial therapeutic modes are frequently incorporated into a combined therapeutic modality termed integrated therapy, which refers to an increasingly popular approach to the treatment of clients presenting with a dual diagnosis, and involves traditional standard of care practices used in the treatment of specific types of mental illness which is enhanced by the addition of CBT, motivational interviewing and/or brief interventions in an effort to address simultaneously the dual contributory components of the clinical diagnosis (Brems et al, 2006). Assessment of Co-Occurrence of Mental Health and Substance Misuse Problems The co-existence of mental health and substance misuse issues represents a complex matter for clinical assessment. Oftentimes, the mental health issues and psychological conditions that may contribute to the excessive use of alcohol or the misuse of drugs are masked by the overtly addictive behaviours (Drake & Wallach, 2000; Brems et al, 2006). It is very difficult to diagnose the origins of mental illness in individuals whose addictive behaviours distort their cognitve processes, emotional stability and may even contribute to psychotic episodes (Abrams et al., 2000) Clinical assessment protocols are challenged by these co-morbidities that must be dissected carefully to reveal their origins (Gold & Frost-Pineda, 2005). In this context, the nature of the clinical presentation will vary depending on the type and severity of the mental illness and the extent and type of substance misuse (Brems et al., 2006). Current evidence in the UK indicates that up to 75% of individuals who misuse drugs are also diagnosed with mental health problems (Abrams et al., 2000) Likewise, approximately 50% of clients with alcohol problems are diagnosed with mental health problems. Most strikingly, approximately 40% of clients diagnosed with mental health problems have also been found to misuse alcohol or drugs (Brems et al., 2006). The statistics further indicate that the percentage of individuals presenting with this type of co-morbidity has risen by over 60% in the UK between the years1993-1998 (Gold & Frost-Pineda, 2005). The Epidemiological Catchment Area Study conducted in the USA as well as research studies from the UK indicate that the substances most commonly misused by individuals with mental health problems are cannibis and alcohol (Drake & Wallach, 2000)..Current statistics indicate that the most common mental health condition that displays co-morbidity with alcoholism is depression (12%), whereas schizophrenia is the most common mental health disorder coincident with drug abuse (15%) (Abrams et al., 2000; Brems et al., 2006). The extent of this problem of co-occurring mental health and substance misuse problems affects not only clients, their families and caretakers but also affects society, in that this group of clients is generally socially maladjusted and unable to work or engage in productive social relationships (Drake & Wallach, 2000). The social maladjustment may also give rise to violent behaviour in some seriously ill individuals. It is clear that substance misuse represents an extremely important problem that exacerbates mental health illnesses. Mental health clients who misuse drugs and/or alcohol may experience increased severity of psychological problems and symptoms (Brems et al., 2006). In addition, these clients may fail to take prescribed medications, and experience a reduced capacity to provide for their own needs, both socially and economically. There is a greater likelihood of imprisonment, hospitalization, suicide and homicide in this group (Drake & Wallach, 2000). Despite continued efforts to develop social policy issues to address this complex and escalating social problem, these efforts to date have not led to a sufficient management of this healthcare problem (Gold & Frost-Pineda, 2005). Critics have argued that the separation of services for clients with substance misuse and those with diagnosed mental health problems by the Drug and Alcohol Action Teams (DAATs) and the Joint Mental Health Commissioning Groups (JMHCGs), respectively, has done little to provide for clients who present with co-occurring drug misuse and mental health problems (Brunette et al, 2001) . The Joint Future Agenda for health and social care services has been established in the hope of providing better services to this group of clients. There are several important areas of treatment and assessment services for clients with co-morbid mental health and substance misuse problems that have been generally inadequate to meet the needs of this client group (Brems et al, 2006). In many cases, the assessment protocols and treatment services are too narrow to embrace the scope and multifaceted presentation of clients who have co-morbidities of this type (Jerrell & Ridgley, 1995, 1999). There is a lack of communication between providers of services of mental and drug/alcohol addiction. Other problems include a failure to identify patients with co-occurring issues using prevailing assessment tools. Most commonly, individuals are identified as having either mental heal or substance use issues depending on the intake setting. Some of these difficulties arise due to a lack of training of clinical personnel in the area of complicated dual diagnosis of mental health issues that are co-morbid with substance misuse. A critical evaluation of assessment and therapeutic approaches to this problem must define the elements of complexity that comprise a dual-diagnosis of co-occurring mental health and substance misuse problems. The complexity arises in part due to the diversity of interactions between the co-occurring morbidities. For example, primary mental health issues may be a cause of substance misuse and substance misuse may, in turn, cause a greater deficit of mental health function. Likewise, substance misuse may itself produce mental health problems; cycles of addiction and withdrawal may have a devastating effect on mental health and behaviour. Moreover, the cause and effect relationship may be further obscured when the mental health deterioration and addictive behaviours evolve within the same timeframe in an individual. Under these conditions, it is very difficult to establish a definitive diagnosis (Bunton et al., 2000). The concept of dual diagnosis is relatively new, having originated in the 1980s. One of the many problems associated with assessment within this categorization is the question of primacy of one diagnosis over another (Robinson & Berridge, 2003). In order to provide the proper treatment, it is essential to determine whether substance misuse is the primary cause or whether mental health issues are the primary driver of the substance misuse (Swann, 2005). The evidence indicates that a significant percentage of individuals with mental health problems, particularly those suffering from affective disorders such as depression or bipolar disorder, are likely to misuse alcohol or drugs, there are also many cases of addiction that produce secondary mental health symptoms. While the dual diagnosis may identify two co-existing problems, it does little to identify the relationship between the two components. There continues to be considerable disagreement among professional as to whether addictions should be treated separately or concomitantly with psychiatric illness (Robinson & Berridge, 2003). Current assessment parameters used in the diagnosis of these co-morbidities do little to address cause and effect parameters on an individual basis and therefore provide little guidance as to the appropriate structure of therapeutic intervention (Swann, 2005). There continues to exist much scientific debate as to whether alcohol abuse or drug addiction represent distinct diseases as first proposed in the “disease model” of alcoholism, or whether they represent behavioural manifestations of psychological problems (Swann, 2005). Research suggests that individuals with a dual diagnosis of mental health and substance misuse problems require diversified therapeutic and supportive modalities (Brunette et al, 2001). Among the most frequently cited recommendations are a holistic therapeutic approach that addresses the multifaceted needs of this group of clients, including mental, physical and social issues that must be incorporated into a realistic treatment plan (Bunton et al., 2000). . Current attention is focused on the implementation of “integrated treatment “ for this group of clients, which involves the coordinated treatment of substance misuse and mental health problems in a simultaneous fashion with the goal of simultaneously targeting the dual psychological and psychosocial issues in clients suffering from these co-morbidities (Drake, 2007). This approach makes sense based on the presence of the two conditions in this group of patients, and there is documented evidence that treating one issue without significant attention to the other may not produce the desired results since the contributing diagnoses produce interrelated physiological and psychological effects in the mental health client (Swann, 2005). Proponents of integrated care cite several research clinical trials indicating that this client group fares better when this multi-dimensional mode of care is implemented (Bunton et al., 2000). It is essential that a client’s condition be assessed appropriately in order to ensure that an appropriate therapeutic path is chosen (Swann, 2005). Several instruments for assessment are in current use to identify individuals with co-morbid mental health and substance misuse problems. These include the Dartmouth Assessment of lifestyle Instrument (DALI), the Substance Abuse treatment Scale (SATS), and The chemical Use, Abuse and dependence scale (CUAD) (Drake, 2007). It has been noted that these assessment tools consider only health-related issues and may not sufficiently address other social and economic factors that may have a profound effect on the individual (Bunton et al., 2000). . The general parameters of assessment include several distinctive areas (Bunton et al., 2000). The first is detection, which involves a determination of the type of mental health issue and substance abuse activities present in a client. Detection is a very difficult, yet critical stage of assessment, since errors at this primary level of intervention may have a profound effect on the level and type of care administered to a client. It is critical that clinicians consider the possibility of a dual diagnosis whenever confronted with an individual with substance misuse or mental health issues as a presenting diagnosis as the co-morbidity rates are so high for these groups of clients (Timko, Ilgen, & Moos, 2008). The next step in assessment involves formulation, which involves an attempt to discern the relationship between the various parameters comprising the dual diagnosis. Extensive interviews may be required to identify the relationship between mental illness, substance misuse and other social and/or health problems that may co-exist in an individual client. The next stage is risk assessment, and this involves a determination of the primary behaviours of an individual that place him/her at greatest risk and therefore deserve immediate attention (Timko, Ilgen, & Moos, 2008). This is a needs based assessment that determines the hierarchy of care protocols provided to the client. Client medical and mental health history often provides a good indication of risk assessment. The next stage involves goal development, which is essentially a strategic plan of intervention designed to meet behavioural and functional goals in an individual client. Other important assessment parameters should include the planning of care delivery, which frequently involves inter-agency cooperation and communication (Timko, Ilgen, & Moos, 2008). Continuous monitoring of client progress and modifications of treatment plans as needed comprise essential components of clinical assessment (Bunton et al., 2000). This requires extensive client follow-up and communication between service providers engaged in the assessment process; unfortunately, these elements have frequently been found to be lacking in the assessment of clients with this type of co-morbidity, resulting in a failure to diagnose the dual nature of the presenting illness and/or inadequate treatment plan implementation. (Timko, Ilgen, & Moos, 2008). The dearth of client follow-up data and regular assessment monitoring also makes it more difficult to assess the potential efficacy of different therapeutic approaches in absence of reliable and consistent clinical data (Brunette et al, 2001). Interventions Clients who receive a dual diagnosis of mental health problem associated with substance misuse represent an extremely diverse client group, and effective intervention strategies must take the multifaceted nature of this dual diagnosis into account if they are to be successful (Robinson & Berridge, 2003). Research suggests that there is no one therapeutic modality that is most beneficial to this group of clients; moreover, the combined elements of addiction, mental illness and the physiological and psychological effects of substance misuse makes this group of mental health clients very challenging to therapists (Garcia & Mann, 2003). The integration of therapeutic modalities frequently involves a combination of pharmacologic care designed to address the mental health issues such as depression or schizophrenia, traditional standard of care therapies and additional psychosocial therapies including motivational interviewing, cognitive behavioural therapy (CBT) and brief interventions that provide intense, short term therapies designed to elicit greater client awareness and understanding of their problems and the behavioural incentives to effect change (Barrowclough et al., 2000; Drake, 2007). . There are a number of general recommendations regarding therapeutic intervention approaches that have received the widespread support of clinicians (Carey et al., 2000; Drake, 2007). Many of these are simple commonsense advisories, including the importance of effective client communication, flexibility of approach, and the inclusion of realistic therapeutic goals designed to meet the therapeutic needs of each individual client. It is also generally recognized that the complexity of this diagnosis means that extended, long-term treatment plans are usually necessary to meet the needs of this group of clients (Robinson & Berridge, 2003). Clinicians generally agree that there are several specific stages of intervention (Drake & Muesner, 2000; Drake, 2007). The first is termed engagement, which involves the initial contact between the therapist and the client and requires the establishment of a relationship based on trust and support. The next step involves a determination of the needs of the client and a concerted effort to meet the primary needs of housing, medication and other basic requirements. Once the basic needs of the client are addressed, the stage of active intervention can begin, in which the therapist attempts to facilitate an understanding of the issues confronting the client regarding the nature of his/her condition and all relevant issues pertaining to the dual diagnosis (Kline & Mehler, 2006 . This involves an attempt by the therapist to explore the problems with the client in ways that are enlightening to both client and therapist. The therapist must attempt to view the issues from the client’s perspective in order to develop a more empathetic relationship and to understand the client’s individual needs. Among the techniques used at this stage of invention are motivational interviewing and cycle of change concepts in an attempt to guide the client’s thinking toward a positive, motivated frame of mind that may accommodate behavioural changes (Drake, 2007). Motivational Interviewing is also known as persuasion and is designed to strengthen the client’s desire to change his/her behaviour (Drake & Muesner, 2000). This type of intervention is neither confrontational nor authoritative; rather, it seeks to involve the client in his/her treatment plan by facilitating an acknowledgement of the important issues and eliciting the motivation to produce change on the part of the client (Kline & Mehler, 2006). Among the techniques utilized in motivational interviewing are education and persuasion (Miller & Rollnick, 1991). The client is informed in a non-threatening manner about drugs and alcohol and their effects on the mind and body. Part of the education process involves an open discussion of the clinical facts, such as drug test results, and other physiological and mental health issues relevant in a particular case. The goal is to make the client more aware and accepting of his/her mental and physical condition and the effects of the addictive behaviours (Kline & Mehler, 2006). A balance sheet of “pros and cons” can be addressed to explore the potential benefits of behavioural changes. A discussion of appropriate medications and treatments is included in the motivational interview approach. In this therapeutic modality, the client is actively engaged in the therapeutic process and, if successful, is led to become the architect of a changed lifestyle (Miller & Rollnick, 1991). Motivational Interviewing is in part related to the stages/cycles of change theory proposed by Prochaska and DiClemente, who proposed a wheel of change that incorporates the notion of a cyclical process that may require repetition to achieve the stated goal (Prochaska et al., 1995). This model incorporates relapse and renewal as part of the change process. This approach is in sharp contrast to the confrontational approaches used in the treatment of clients with addiction in traditional therapeutic approaches to drug and alcohol addiction (Gulliver et al., 2008). The goal in dual diagnosis therapy approaches involving motivational interviewing is to enlist the client in the recognition of the problem and to motivate a willingness to become part of the solution (Miller & Rollnick, 1991). A controlled randomized trial of motivational interviewing, CBT and family intervention in a group of patients with a dual diagnosis of substance misuse and psychiatric disease (schizophrenia) conducted by the American Psychiatric Association (Drake & Muesner, 2000). The results of this study indicated that the integrated treatment program produced a greater therapeutic benefit compared to patients who received only standard care. Levels of general functioning were superior in this group of patients, as well as a decrease in positive symptoms and increased abstinence from drug and alcohol use throughout the 12 month period of study. This study indicated that a combined treatment program including motivational interviewing, CBT and family intervention produced positive clinical results in a controlled case study, which is supportive of these therapeutic approaches administered as a supplement to standard psychiatric care. A different conclusion was reached in a review of psychosocial treatments of patients with a dual diagnosis of substance misuse and a psychiatric illness, including depression, bipolar disorder, schizophrenia or other serious mental illness (Drake & Muesner, 2000). A review of 59 studies showed a poor replication of individual study findings, which were limited in number overall. Moreover, the authors concluded that, based on currently available research clinical trial data, no single therapeutic approach was successful in the treatment of both psychiatric and substance abuse disorders (Carey et al., 2000). The study indicated that existing therapeutic approaches to psychiatric illness were also effective in decreasing substance misuse, that effective approaches to psychiatric illness were also effective in patients with a dual diagnosis. Most importantly, the authors could find no conclusive evidence to support the benefit of integrated treatment approaches in patients with a dual diagnosis. What is clear is the need for further controlled studies to explore the clinical benefit of integrated treatment approaches in this group of patients. Currently, there is no conclusive evidence to support the concept that integrated approaches including motivational interviewing, CBT or intervention have a sustained long-term clinical benefit in patients with a dual diagnosis of mental illness and substance misuse (Garcia & Mann, 2003). Cognitive Behavioural therapy (CBT) is rooted in behaviourism and cognitive psychology (Barrowclough et al., 2000). The goal of this therapeutic approach is the treatment of psychological problems by a process of “enlightenment” that introduces new ways of thinking about and understanding psychological issues affecting an individual client (Drake & Muesner, 2000). This cognitive approach to therapy attempts to involve the client in his/her treatment by suggesting novel approaches to distorted or dysfunctional ways of thinking or dealing with personal problems. The behavioural component enlists the clients’ re-evaluation of detrimental and destructive behaviours and attempts to elicit altered behavioural patterns based on new cognitive awareness and behavioural modification (Garcia & Mann, 2003). The therapist probes important issues with the client in an attempt to derive new approaches in behaviour and thought processes responsible for behaviour, CBT has been used successfully to treat many mental health and behavioural problems (Mueser et al., 2005). Whilst its use has been associated with a positive therapeutic outcome in patients with depression, anxiety, obsessive compulsive disorder and other mental health issues, its effectiveness in the treatment of severe mental illnesses such as bipolar disorder or schizophrenia is highly disputed (Harrison et al., 2008). Moreover, the effectiveness of CBT in the treatment of individuals with substance misuse problems is also highly controversial. These areas of controversy call into question the potential effectiveness of CBT in clients with co-morbidities involving these two areas. Critics argue that the use of CBT in this group of clients has produced little evidence of sustained behavioural changes as they relate to either the problem of substance misuse or the associated mental health condition (Gulliver et al.., 2008). Proponents of CBT argue that one of the chief barriers to effective therapy in clients with a dual diagnosis is the lack of compliance, cooperation or even the acknowledgement of significant mental health and/or substance misuse on the part of the client (Brunette et al, 2001). The extraordinary denial and poor coping skills associated with a general lack of awareness of the significance of the ongoing health and substance misuse issues is an often-cited cause of treatment failure associated with failure to take prescribed medications or to avail oneself to critical healthcare services (Steinberg & Williams, 2007). Though it is not a substitute for pharmacologic and standard psychiatric care practices, in this context CBT may be an appropriate therapeutic tool to address the psychosocial needs of clients with co-morbidities in these areas (Davidson et al., 2008). A review of 54 research studies involving clients with a dual diagnosis of substance and misuse that compared psychosocial intervention approaches indicated that motivational interviewing was the most successful therapeutic strategy in reducing short-term substance abuse in this group of patients (Robinson & Berridge, 2003). This review indicated that, when combined with CBT, improvements in clients’ mental state and functions were also noted. CBT used as the sole therapeutic approach, produced little clinical benefit in this group. Integrated therapeutic approaches in long-term residential programs also indicated some clinical benefit; however, the data were not as consistent in this area. There is considerable positive research data on the efficacy of integrated mental health treatment and substance misuse therapies in patients with a dual diagnosis (Dadich & Swift, 2008). The positive clinical benefits include decreases in substance use and improvements in mental health. There is little doubt that combined therapeutic approaches that address consistently the substance abuse and mental health issues of clients with these co-morbidities profit from this integrated therapy (Steinberg & Williams, 2007). Traditional standard of care practices for the treatment of mental illness and substance misuse occurring independently or as co-morbidities in dual diagnosis generally involves long-term approaches that often require many months to years of intervention (Drake & Muesner, 2000). Problems associated with these approaches involve difficulties in achieving client commitment to long-term therapy, and attrition represents a very serious problem in this group of clients (Mueser et al., 2005). More recently, the concept of “brief interventions” has been introduced (Carey et al., 2000). This approach involves a short-term intervention that may involve any number of single or combined psychosocial therapies designed to produce rapid behavioural changes and increased understanding of important health issues that may cause the client to engage more fully in therapeutic recovery and decrease behaviours associated with substance misuse (Brunette et al., 2001). The duration and intensity of this approach varies with individual programmes, but generally ranges from 3-18 months duration. The goal of this therapeutic approach is to effect a change in the client with a dual diagnosis that will result in improved mental or function and behavioural changes that may set a course for continued gains in the context of longer-term therapy, compliance with prescribed pharmacologic regimens and improved coping skills in lifestyle management (Dadich & Swift, 2008). Proponents of brief interventions cite the importance of rapid changes in client behaviour and perceptions as critical to the success of longer-term therapeutic approaches in this group of highly treatment resistant clients (Brunette et al., 2001). It is easier to enlist compliance to a brief regimen of intense psychosocial therapy that may facilitate client participation in more extended therapeutic regimens (mueser et al, 2005). Moreover, rapid positive results may encourage the client to continue to seek mental health services. Critics of brief intervention cite clinical statistics suggesting that behavioural and psychosocial gains are at best transient and inconsistent, and that even minimal improvements often result in relapsed behaviour as soon as the intervention efforts cease (Steinberg & Williams, 2007). Researchers argue that the apparent positive gains associated with brief intervention are most often the result of a therapeutic “placebo effect” that wanes rapidly once the client is no longer the focus of intense interventional efforts (Brunette et al., 2001). The results of several research studies on brief interventions in psychiatric patients for the misuse of addictive substances showed that six months of motivational interviewing was associated with lower levels of substance use that maintained for at least 12 months compared with patients receiving standard care only (Carey et al., 2000). These data suggest that short term interventions may be a relevant therapeutic tool to achieve modest gains in mental health outlook and behaviour in this group of clients. Further studies will be needed to assess the benefits of this therapeutic tool in the treatment of clients with a dual diagnosis. Conclusion As the prevalence of mental health clients presenting with a dual diagnosis of mental illness combined with substance misuse problems has increased dramatically over the past several decades, clinicians and policymakers have attempted to develop improved means of diagnosis, assessment and treatment for this group of mental health clients (Carey et al., 2000). These efforts have complicated by the multifaceted nature of these co-morbidities and the ranges of mental health conditions and substance misuse issues experienced in these individuals (Davidson et al., 2008). The issues are further complicated by a lack of understanding of the intricacies of cause and effect relationships between the dual clinical manifestations (Steinberg & Williams, 2007). Despite these difficulties, increasing attention has been focused on the importance of thorough and adequate assessment of clients with diagnosed mental health conditions or substance misuse problems to identify individuals with co-morbidities involving both areas (Dadich & Swift, 2008). This is essential in order to implement effective therapeutic regimens that will address simultaneously the mental illness and behavioural misuse of drugs or alcohol that characterize the composite health condition of clients with a dual diagnosis (Davidson et al., 2008). Significant research studies suggest that the treatment of only one of these conditions in clients with dual diagnosis is far less effective than therapeutic regimens involving integrated approaches that address both areas of dysfunction with equivalent and targeted therapeutic approaches (Carey et al., 2000). An important focus of this essay was the appropriateness of psychosocial therapies including CBT, motivational interviews and brief interventions in the integrated care of clients with dual diagnosis (Drake & Muesner, 2000). Each of these therapeutic approaches is designed to achieve changes in cognitive awareness and behaviour that will augment standard of care mental health therapeutics in this group of patients (Mueser et al., 2005). These cognitive and behavioural changes may result in improvements in mental health, treatment compliance, and lifestyle coping skills associated with decreased use or abstinence from drugs and alcohol. The therapeutic goals for this group of clients are consistent with these therapeutic modalities and research studies, in general, have suggested positive effects in this group of clients when compared to control groups receiving standard of care therapies only (Harrison et al., 2008). Moreover, the consensus of data currently suggests that motivational interviews are the most successful individual approach when used in brief interventions or longer term therapeutic settings (Drake, 2007).. CBT used by itself has produced little observable clinical benefit in this group of clients; however, recent research clinical trial data suggest that CBT and motivational interviews together may elicit more positive responses than motivational interviews only (Barrowclough et al., 2000). Data on the long-term benefits of brief interventions are inconclusive; current study results suggest that most gains achieved in brief interventions are short-term and must be incorporated into longer term treatment plans to achieve consistent results in this client group (Dadich & Swift, 2008). The increasing attention to the assessment and integrated treatment of clients with a dual diagnosis represents an important effort to address the healthcare needs of this ever-growing group of mental health clients (Mueser et al., 2005). Many more research studies are needed to define a consistent and appropriate set of therapeutic regimens that will address the multi-faceted needs of this diverse group of clients. Current evidence suggests that integrated therapeutic approaches involving the supportive use of combinations of motivational interviews, CBT and brief interventions that incorporate these therapeutic principles may play an increasingly important role in the clinical management of mental health clients with a dual diagnosis of mental illness and substance misuse (Dadich & Swift, 2008). References Abrams, D, B., Herzog, T, A, Emraons, K. M, & Linnan, L. 2000. Stages of change versus addiction: a replication and extension. Nicotine and Tobacco Research, 2, 223—229. 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Steinberg, M., & Williams, J. 2007. Psychosocial treatments for individuals with schizophrenia and tobacco dependence. Journal of Dual Diagnosis, 3(3), 99 – 112. Swann, A. 2005. Bipolar disorder and substance abuse. Journal of Dual Diagnosis. 1(3), 9-23. Timko, C., Ilgen, M., & Moos, R. 2008. Predictors of dually diagnosed patients psychiatric symptom exacerbation during acute substance use disorder treatment. Journal of Dual Diagnosis, 4(1), 55 – 74. MENTAL HEALTH PROBLEMS Read More