Psychosocial Interventionsfor Adults with Severe Mental Illnesses

and Co-Occurring Substance Use Disorders:A Review of Specific Interventions

Kim T. Mueser, PhDRobert E. Drake, MD, PhD

Stacey C. Sigmon, PhDMary F. Brunette, MD

ABSTRACT. A growing body of research supports the effectiveness ofintegrated treatment for people with co-occurring severe mental illnessand substance use disorders (dual disorders), but the effects of specificinterventions are less clear. This review focuses on the effects of specificpsychosocial interventions for dual disorders, including individual,group, and family modalities, as well as structural (e.g., case manage-ment model), procedural (e.g., contingency management), residential,and rehabilitation (e.g., vocational) interventions, with an emphasis onrandomized controlled trials. Controlled research on specific individualinterventions has focused mainly on motivation enhancement ap-proaches for clients in the earlier stages of treatment, and has reported

Kim T. Mueser, Robert E. Drake, and Mary F. Brunette are affiliated with the De-partment of Psychiatry, Dartmouth Medical School, New Hampshire-Dartmouth Psy-chiatric Research Center.

Stacey C. Sigmon is affiliated with the Department of Psychiatry, University ofVermont.

Address correspondence to: Kim T. Mueser, PhD, New Hampshire-Dartmouth Psy-chiatric Research Center, Main Building, 105 Pleasant Street, Concord, NH 03301(E-mail: kim.t.mueser@dartmouth.edu).

Journal of Dual Diagnosis, Vol. 1(2) 2005http://www.haworthpress.com/web/JDD

2005 by The Haworth Press, Inc. All rights reserved.Digital Object Identifier: 10.1300/J374v01n02_05 57

improved retention in treatment and substance abuse outcomes. Groupinterventions have been most extensively studied, with findings indicat-ing that a variety of different treatment approaches specifically designedfor dual disorder clients (e.g., emphasizing education, motivational en-hancement, cognitive-behavioral counseling) are more effective at improv-ing substance abuse outcomes than no group treatment or standard 12-Stepapproaches. Structural studies suggest that increasing the intensity of in-tegrated dual disorder treatment produces only modest benefits. Resi-dential dual disorder programs show great promise, especially for clientswho are homeless and without psychosocial supports. Research on fam-ily therapy, procedural interventions, or rehabilitation is too prematureat this time to draw any conclusions, although promising results haveemerged in each area. Future avenues for research on specific interven-tions for dual disorders are considered. [Article copies available for a feefrom The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<docdelivery@haworthpress.com> Website: <http://www.HaworthPress.com>© 2005 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Dual diagnosis, dual disorders, co-occurring disorders,substance abuse, substance misuse, mental illness, psychosocial, reha-bilitation

A recent review of the literature on psychosocial interventions foradults with severe mental illnesses and substance use disorders foundrelatively strong evidence for the principle of integrating mental healthand substance abuse treatments (28). Between 1994 and 2003, 26 con-trolled studies were reported in this area, and most showed evidence forthe effectiveness of a more integrated approach over a less integratedapproach. There was little consistency, however, in the specific inter-ventions, the methods, and the results. Studies assessed different mix-tures of various individual, group, family, and housing interventions,with little replication of specific interventions. Methods ranged fromquasi-experimental to experimental, with problems related to attrition,standardized assessment of outcomes, fidelity, treatment drift, and soforth. Most studies showed differences on some but not all mentalhealth, substance abuse, housing, institutional, or quality of life out-comes.

The aim of this review is to examine more carefully specific interven-tions for people with severe mental illnesses and co-existing substance

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use disorders. We divide the interventions into types: individual therapies,group therapies, family therapies, structural interventions (e.g., types ofcase management, day programs), procedural interventions (e.g., con-tingency management, money management), housing interventions,and vocational rehabilitation interventions. Within each category, weattempt to specify the interventions, the targeted outcomes (e.g., mentalhealth symptoms, substance abuse symptoms, stable housing), and theclient’s stage of treatment. The “stages of treatment” refers to the differ-ent stages clients progress through when they recover from a dual disor-der through work with professionals, including becoming engaged in atrusting, therapeutic relationship (“engagement”), developing motiva-tion to work on substance abuse problems (“persuasion”), activelyworking on reducing substance use and achieving sobriety (“activetreatment”), and striving to prevent relapses and expand their recoveryto other areas of functioning (“relapse prevention”) (62, 73). As clients’motivation to address their substance use problems differs from onestage to another, tailoring interventions to clients’ stage of treatmentmay optimize outcomes.

For this review, we define commonly used terms as follows: “Severemental illness” refers to major mental illnesses, such as schizophrenia,bipolar disorder, and depression, when they are associated with pro-longed disability. “Substance use disorder” refers to abuse or depend-ence on alcohol or other drugs of abuse (omitting nicotine). “Dualdiagnosis” and “dual disorders” refer to co-occurring, or co-existing,severe mental illness and substance use disorder. Last, we use the abbre-viation “RCT” to refer to research studies that employ a randomizedcontrolled trial design.

INDIVIDUAL THERAPIES

A variety of individual therapies are commonly used with dual diag-nosis clients. These include interventions that target mental health, sub-stance abuse, or post-traumatic symptoms. Most build on cognitive-behavioral, motivational enhancement, or 12-step models. Standard-ized therapies for mental health problems, such as social skills trainingand supportive psychotherapy, have not been studied specifically withdually diagnosed clients.

Several substance abuse interventions have been tailored specificallyfor dual diagnosis clients, including psychoeducational counseling,12-step counseling, motivational counseling, cognitive behavioral

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counseling, and skills training. In many studies the substance abusecounseling intervention is instead part of a larger case management in-tervention that includes individual counseling, group treatment, andother interventions (17, 26, 32, 45, 49). In other studies the substanceabuse counseling intervention is well specified but combined with otherinterventions, such as family therapy (6).

The only stand-alone individual therapy that has been tested in con-trolled studies is motivational counseling. Baker et al. (2002) andSwanson et al. (1999) independently tested the hypothesis that one mo-tivational session in the hospital would help clients in the engagementphase to attend outpatient treatment. Swanson et al. found evidence ofgreater likelihood of attending a first outpatient session, while Baker etal. found no differences in clinic attendance. Graeber et al. (2003) usedan RCT to compare three motivational sessions versus three educationalsessions with male veterans with schizophrenia and alcohol use disor-der, and found that the motivational counseling group had a greater rateof abstinence and fewer drinking days four months after treatment.Only alcohol outcomes were assessed. Stage of treatment for these cli-ents at baseline was unclear. In an RCT, Kavanagh et al. (2004) evalu-ated the effects of 3 hours of individual counseling that focused onrapport building and motivational interviewing in hospitalized recentonset psychosis clients. Substance abuse outcomes at 6- and 12-monthsfavored the motivational enhancement intervention over standard care.Engagement and retention in services was still a problem in this study,perhaps in part because the study focused on clients with a first episodeof psychosis, who often present special challenges in retention in treat-ment (33).

There is substantial potential for individual interventions that targetthe psychological consequences of trauma, such as posttraumaticstress disorder (PTSD), to reduce substance abuse, particularly in therelapse prevention stage. There is a high comorbidity between sub-stance abuse and PTSD both in the general population (12, 46) andamong persons with severe mental illness (65, 98). Similarly, there isconsiderable overlap between PTSD and severe psychiatric disorders(11, 63). The use of substances to either dampen trauma-related prob-lems, such as difficulty sleeping (68), or to escape from memories oftraumatic experiences, may pose special challenges as clients’ attain so-briety and their memories of abuse and its impact on their lives becomeclearer. Several standardized interventions have been developed to ad-dress the problem of co-occurring post-traumatic reactions, substanceabuse, and mental illness, including individual-based cognitive-behav-

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ioral treatment (64), and group-based interventions (38, 67). Unfortu-nately, mental health and trauma interventions have not been testedspecifically with dual diagnosis clients or in relation to their effects onsubstance abuse symptoms, although research in this area is underway.

GROUP THERAPIES

Group intervention has a major appeal in the treatment of substanceuse disorders for at least two reasons. First, as substance use is often asocial behavior (16), the use of group processes to develop social sup-port and establish different social norms offers the opportunity to capi-talize on these processes. Second, group interventions may be a moreefficient treatment modality than individual-based treatment, althoughcost-effectiveness analyses remain to be done. A variety of differentmodels of group intervention have been studied and empirically vali-dated in the substance abuse treatment field (57), with less research onpersons with co-occurring disorders.

Early studies of group intervention for persons with co-occurring dis-orders were methodologically flawed, and produced mixed results. Inone of the first studies of group intervention, Bond and colleagues(1991), using a quasi-experimental design (with some but not all clientsrandomized to different treatments), compared substance abuse “refer-ence groups” for clients with dual disorders with assertive communitytreatment (ACT) and standard care across three community mentalhealth centers. The reference groups across the two sites that offeredthis intervention differed somewhat in their approach. At one center thegroup focused primarily on engagement and peer support. At the othercenter, engagement was done mainly on an individual basis, with subse-quent group work focusing more on motivational enhancement througheducation and exploration of how substance use had affected clients’lives. Results at 18 months indicated that clients who received the groupintervention had better retention in services (83%), compared to 65%for ACT and 40% for standard care. Other outcomes were mixed, withsome suggestion of greater improvements in substance abuse for thegroup intervention. This study suggests that group intervention may beeffective for the engagement and persuasion stages of substance abusetreatment.

Another early study of group intervention reported less promising re-sults. Lehman et al. (1993) used an RCT to study clients with a dual di-agnosis receiving either intensive case management plus group

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intervention or standard care. Group treatment involved participation inthe “Being Sober Group,” which was a 5-hour a week group developedfor persons with a dual disorder. Attendance at the group interventionwas low (approximately 20% of possible sessions), and substance useoutcomes did not differ at one year. As the name of the group interven-tion implies, the program was aimed primarily at clients who under-stood the impact of substance abuse on their lives, and were motivatedto change (i.e., clients in the active treatment or relapse preventionstages), but not at the engagement or persuasion stages. The results ofthis study suggest that group interventions need to attend to issues of en-gagement and persuasion regarding substance use before teaching theskills necessary for dealing with substance use situations and avoidingrelapses.

Some later studies of group intervention indicate promising resultsfor this population. In a quasi-experimental study (with some but not allclients randomized to different treatments) Jerrell and Ridgely (Jerrell,1996; 1995) compared two different group approaches, based on eithersocial skills training (that included education about substance abuse andskills training in basic interpersonal skills) or modified 12-step ap-proach, to intensive case management for clients with dual disorders.The results indicated that, compared to the modified 12-step approach,the skills training intervention had better substance abuse and mentalhealth outcomes, while intensive case management was associated withless severe symptoms but not less severe substance abuse. These find-ings suggest that group intervention that focuses on both informationabout dual disorders and basic skills development may have positive ef-fects on both substance abuse and mental health outcomes. Althoughthe results of this specific skills training program have not been repli-cated several standardized programs have been developed for dual dis-orders (7, 80) and preliminary data have been reported suggesting itsfeasibility and potential benefits (8).

Hellerstein et al. (1995) compared the effectiveness of twice weeklyintegrated supportive and psychoeducational group therapy to usualservices in a RCT for clients with dual disorders. A higher percentage ofclients in the integrated treatment group remained in treatment at fourmonths (70%) than clients receiving the usual treatment (37%), and ateight months treatment retention was related to better substance abuseand psychiatric outcomes, although differences between the groupswere not statistically significant. This study is consistent with many inthe substance abuse field that demonstrate the importance of treatmentretention for improving outcomes. Lack of differences between the inte-

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grated treatment groups and customary care could be due to any of a va-riety of factors, including low statistical power because of the smallsample size and high attrition, the brief follow-up period, or under-utilization of outreach and other engagement strategies that could haveresulted in better retention in the treatment groups.

One of the strongest studies on the effects of group interventions fordual disorders was an RCT conducted by James et al. (2004). The groupintervention studied consisted of six 90-minute sessions, tailored to cli-ents’ individual stage of change and motivations to use substances. Fol-low-up assessments at three-months post-treatment showed that clientswho received the group intervention had better outcomes than clientswho received usual care in substance abuse, psychiatric symptoms, andhospitalizations. This study provides further support that group inter-ventions that are tailored to individuals’ motivational level to addresssubstance abuse can be effective at improving outcomes, although longer-term follow-ups are needed.

Additional evidence concerning the effectiveness of group interven-tion for dual disorders that is tailored to motivational stage of treatmentis provided by a recently completed quasi-experimental study by Aubreyet al. (2003). These investigators compared the effectiveness of stage-wisegroup treatment groups (including persuasion, active treatment, and re-lapse prevention groups), as described by Mueser et al. (2003) withtreatment as usual in 56 clients, and reported greater benefits in alcoholabuse and satisfaction with daily activities and finances over sevenmonths. This is the first test of group interventions that were explicitlydesigned to address the needs of clients at different levels of motivationto address their substance abuse (i.e., different stages of treatment).

In a RCT, Penn and Brooks (1999) compared two different groupmodels for treating dual disorders in a day treatment setting, based oneither a modified 12-step approach or a cognitive-behavioral approachbased on the rational recovery model. The results were mixed; the12-step approach had better substance abuse outcomes whereas the cog-nitive-behavioral approach had better hospital outcomes. Interpretationof the findings is marred by the relatively high drop out rate, a commonproblem in studies of day treatment or residential programs. The resultsalso underscore the difficulty establishing differences between differentgroup approaches to integrated dual disorder treatment.

Drake et al. (1997) compared a cognitive-behavioral group interven-tion with a social network intervention in an RCT among clients whowere receiving integrated dual diagnosis treatment. Both group inter-ventions were tailored to clients’ individual stages of change. These cli-

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ents were compared with clients who received standard services in aquasi-experimental design. Clients who received integrated treatmentalso received housing supports and integrated case management. Cli-ents in the two group interventions did not differ in their outcomes at18-months (data not published), but clients who received integratedtreatment had significantly better substance abuse and housing out-comes than those who received usual care. This study supports the find-ings from other studies suggesting that different forms of active grouptreatment are helpful but not differentially helpful.

Finally, Weiss and colleagues developed a 20-week relapse preven-tion group for clients with bipolar and substance use disorders, and sub-sequently studied 45 private hospital clients in a quasi-experimentalstudy. Substance abuse and abstinence outcomes were significantlybetter for the relapse prevention group. The focus of this group on theprevention of relapse suggests that clients were motivated to reducetheir risk of relapse and were therefore in the later motivational stages oftreatment. It should be noted that this study was conducted in a privatehospital setting, and the clients do not appear to have been as disabledby chronic illness as those in many studies.

In summary, group interventions provide moderately strong supportfor the effects of integrated treatment for persons with co-occurring dis-orders. Across different studies, there is some evidence that clients whoattended groups consistently (e.g., for a year or more) had better out-comes, although even some shorter-term groups had positive outcomes(47). The better outcomes associated with longer-term participation ingroup intervention could reflect the impact of group work on outcomes,or the fact that clients who achieve and remain sober are more likely tostay in substance abuse treatment of any kind, a finding widely reportedin the substance abuse field (59, 92, 93). It is noteworthy that despite therelatively large number of studies in this area, no replication studies ofgroup interventions have been reported. Replication of research find-ings is at the very heart of science. Accordingly, replication of treatmenteffects is an important priority for future research in this area.

On a final note, self-help groups such as Alcoholics Anonymous(AA) (104), or groups specifically focused on persons with a dual diag-nosis such as Dual Recovery Anonymous (37) or Double Trouble (102)may play an important role in supporting recovery from dual disorders.While self-help organizations are not formal “treatment,” they provideaccess to social support from individuals who endorse sobriety, whichmay substitute for social contacts with substance users and improve out-come (100). Although experimental research has not been conducted in

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this area, one cross-sectional study found that participation in Dual Re-covery Anonymous was associated with lower mental health and sub-stance abuse symptoms, and higher levels of personal well-being,whereas participation in AA was not (52). These findings suggest thatmodifying the traditional AA approach to incorporate more attention topsychiatric symptoms may be of benefit to persons with dual disorders,consistent with reports of some such clients regarding difficulties par-ticipating in traditional self-help groups (71). More longitudinal re-search on the role of self-help in recovery from a dual diagnosis isneeded.

FAMILY THERAPIES

Family interventions are among the most powerful psychosocialtreatments for both substance use disorders (94) and psychiatric disor-ders (24). Research on persons with co-occurring disorders participat-ing in integrated dual diagnosis treatment shows that the number ofpeople using substances in clients’ social networks predicts a worsesubstance abuse outcome (100). However, despite the strong evidencedocumenting the effects of family work for substance abuse and (sepa-rately) for mental illness, very little research has examined its effects inpersons with dual disorders. Although the reasons for this are unclear, itis possible that the challenges of working with families of persons withdual diagnoses are compounded by the fact that substance abuse in thispopulation often results in the loss of family support and housing stabil-ity (18, 19), and by the high rates of substance abuse in those familymembers (69).

One RCT compared the effects of usual care versus nine months ofcombined family intervention for schizophrenia and substance abusewith individual counseling that included both cognitive-behavior ther-apy for psychosis and motivational interviewing (6, 36). Consideringthe emphasis of this program on education and practical problem solv-ing about substance abuse issues (for the family), and motivational in-terviewing and strategies for managing persistent symptoms (for theclient), this program appears to have been geared to address individu-als’ stages of change in the engagement, persuasion, and active treat-ment stages of treatment. Outcomes at 12 months favored the familyand individual intervention in terms of global functioning, substanceabuse, symptoms, and hospitalizations. At 18 months most of these

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gains had been maintained, although the groups were no longer signifi-cantly different in substance abuse.

No controlled studies have examined the impact of family interven-tion alone on substance abuse outcomes in clients with dual disorders.However, pilot work on a model combining individual family work,based on behavioral family therapy, with multiple-family supportgroups has yielded promising results for clients with co-occurring dis-orders (60), and controlled work is currently underway. More work isclearly needed in this area, considering the high rate of family contactwith people with dual disorders (21), and the devastating effects of sub-stance abuse on family members caring for a mentally ill relative, in-cluding distress, physical assaults, and economic expenditures. On thepositive side, research shows that family involvement in the care of per-sons with dual disorders is associated with a better course of the disor-ders, providing hope that family intervention that supports suchinvolvement may confer a clinical benefit, and reduce burden on thefamily (22).

STRUCTURAL INTERVENTIONS

Structural interventions involve changes to the health care system bywhich mental health and substance abuse services are delivered, such ascase management models or day treatment compared to less intensiveoutpatient treatment. Several studies have examined different ap-proaches to case management for clients with dual disorders, althoughthe nature of the comparison groups is markedly different across thestudies.

Drake et al. (1998), using a RCT, compared the effectiveness of twodifferent case management models for delivering integrated treatmentfor dual disorders: assertive community treatment (ACT) (95) withstaff:client ratios of 1:10 and standard case management with staff:cli-ent ratios of 1:30 in a multi-site, three year outcome study. Clients inboth case management models received a comprehensive array of inte-grated dual disorder services, including outreach to engage clients inservices, individual motivational interviewing, stage-wise group treat-ment, and pharmacological management. Overall, results for both stan-dard case management and ACT were very good, with the ACTapproach indicating slightly better (but probably not clinically signifi-cant) outcomes for alcohol abuse, symptoms, and quality of life. Thisstudy supported the viability of delivering comprehensive integrated

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services to most clients with dual disorders through standard case man-agement, and suggested that most clients can be treated effectivelywithout more intensive ACT services.

In a similar but smaller study, Godley et al. (1994) also used a RCT tocompare the effectiveness of integrated dual disorder services providedthrough intensive case management with standard clinical case man-agement over two years in a RCT. Also similar to Drake et al. (1998)findings, outcomes slightly favored the more intensive case manage-ment group in days of using drugs, but not other outcomes. The resultsof these two studies suggest that when integrated dual disorder servicesare held constant, the case management model employed to deliverthose services has at most only a modest impact on the clinical out-comes. The implications of the findings are that the search for more ef-fective integrated treatments for co-occurring disorders is more likely tolie within the realm of the services themselves rather than the organiza-tion’s structure of those services.

Three studies, one experimental (17) and two quasi-experimental(32, 45), have compared a combination of different service delivery sys-tems with different clinical services for clients with dual disorders. Ineach study, more intensive and more outreach-oriented services werecombined with more integrated dual disorder clinical interventions, in-cluding integrated groups, which were combined with less intensiveservices and fewer integrated treatments. Across all three studies, theoutcomes clearly favored the more intensive and more integrated ser-vices in terms of substance abuse and mental health functioning. How-ever, these studies do not shed light on the relative contributions of theservice system changes compared to the clinical interventions them-selves. Considering the research previously reviewed in this sectioncomparing more intensive with less intensive case management models,and research reviewed in the previous section on group interventions, itis plausible that the better outcomes for the integrated interventions inthese studies reflect the impact of integrated group interventions on sub-stance abuse and other outcomes.

It is interesting to note that with the exception of the Penn and Brooks(1999) study, which compared different group approaches to dual disor-der treatment in a day treatment program setting (reviewed in Group In-terventions section), no other studies have evaluated specificallytailored day treatment or other intensive outpatient programs, despitetheir popularity in the substance abuse field. One possible explanationfor the lack of research in this area has been the growing consensus inthe psychiatric rehabilitation field that while day treatment or partial

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hospitalization approaches are viable alternatives to longer-term inpa-tient treatment, there is a lack of evidence that they improve psychiatricoutcomes compared to less intensive outpatient treatment (66). Thesefindings are consistent with one of our earliest reviews of the literatureon day treatment programs for dual disorders with little support for theireffectiveness (27).

PROCEDURAL INTERVENTIONS

Contingency management procedures involve the systematic provi-sion of incentives and/or disincentives for specific behaviors of an indi-vidual for the purposes of modifying those behaviors and improvingfunctional adaptation. There are several reasons why contingency man-agement may be potentially beneficial for persons with a dual diagno-sis. First, existing naturalistic contingencies impinging on persons witha dual disorder may inadvertently reinforce substance use behavior. Useof substances is often motivated by the pleasurable effects of sub-stances, efforts to escape anxious or depressed mood states, in responseto boredom, or to facilitate social contacts with others (16, 61, 70). Fur-thermore, financial entitlements may be used to support substance usehabits, with evidence showing that substance abuse is greatest immedi-ately following receipt of such funds (87).

Second, there is abundant evidence that contingency managementapproaches are effective in persons with severe mental illness. Early re-search, including both multiple case studies and controlled trials, hasshown that token economies, which involve the systematic reinforce-ment of desired behaviors, are effective in reducing psychotic behaviorand increasing socially appropriate behavior and self-care skills (4, 74).Studies in this area demonstrate that clients with severe mental illnessare responsive to changes in their environmental contingencies, and arecapable of improving their social behavior if provided with the right in-centives.

Third, research has shown that contingency management, providedas a stand-alone intervention or as an adjunct to more comprehensivetreatment, is effective at improving substance abuse outcomes (40).This approach typically involves the delivery of a tangible reward (e.g.,a voucher), contingent on the client meeting a predetermined therapeu-tic target. The most common targeted behavior is substance abstinence,wherein the client earns voucher-based incentives for laboratory-veri-fied abstinence from recent substance use (e.g., negative urine sample

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or breath alcohol level). Vouchers not only provide a direct reward toclients for achieving periods of abstinence, but they are also then ex-changed for goods and services in the community that further support ahealthy, substance-free lifestyle (e.g., gym membership, educationalclasses, activities with spouse or family). Moreover, an escalatingschedule of voucher earnings has been established to specifically pro-mote continuous durations of abstinence and to prevent relapse (42).Overall, extensive experimental research over the past three decadeshas demonstrated that contingency-management interventions are ef-fective at promoting treatment retention and reducing a wide range ofsubstance use, including nicotine, alcohol, marijuana, cocaine, opiates,and benzodiazepines (41, 43, 44).

While the preponderance of evidence supporting contingency man-agement is with either clients with severe mental illness or substanceuse disorders, a growing body of literature suggests that these strategiescan also reduce problematic substance use among clients with dual dis-orders. Of special interest is the fact that the interventions described be-low have been implemented with clients who have not necessarilyexpressed a strong desire to work on their substance use problems, andare therefore presumably at the earlier motivational stages of change.Contingent incentives have been shown to reduce cigarette smokingamong people with schizophrenia (82, 99). An early study also demon-strated the effectiveness of positive reinforcement (praise, day passesfrom inpatient status) and response cost (fines) contingencies in reduc-ing alcohol use among inpatient veterans with schizophrenia (75). Inthat within subject study, frequency of drinking was reduced from abaseline mean of 55% to 10% during the intervention period and re-mained at reduced levels throughout the 6- and 12-month follow-upphases.

Contingency management interventions have also shown promise inreducing illicit drug use among clients with serious mental illness. Stud-ies utilizing rigorous within subject designs (e.g., no treatment–treat-ment–no treatment) have demonstrated that contingent monetary- andvoucher-based incentives are effective in significantly reducing mari-juana use among clients with schizophrenia, even among individualswho are not seeking treatment for their marijuana use (90, 91). The rep-lication study was significant because it suggested that vouchers can beused to support change in substance use behavior, which may be a moreacceptable reinforcement than cash in many clinical treatment settings,and can be used to support many healthy behaviors. Contingency man-agement has also been found to reduce cocaine use among outpatients

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with schizophrenia. For example, Shaner et al. (1997) conducted a pilotstudy with two homeless, treatment-resistant male outpatients withschizophrenia and cocaine dependence in which during a 2-month inter-vention condition, they earned $25 for urine samples that tested nega-tive for benzoylecgonine, a cocaine metabolite. The proportion ofcocaine-positive tests and mean urinary concentration of benzo-ylecgonine were significantly lower for both participants during the in-tervention compared to baseline conditions. A more recent feasibilitystudy extended the sensitivity of cocaine use in this population tovoucher-based incentives (81). Interestingly, reduction in substanceabuse occurred only during the first two weeks of the four-week study,suggesting there was an important window of opportunity during whichmore intensive psychosocial intervention may be required. A recentRCT showed that contingent management of Social Security disabilitybenefits (vs. non-contingent management) led to decreased alcohol anddrug use in a pilot study of 41 clients with severe mental illness and sub-stance dependence (79).

In summary, a growing literature demonstrates that substance useamong individuals with dual disorders may be sensitive to contingentincentives for abstinence. The studies conducted to date have method-ological limitations, including the fact that there are few RCTs, manyhave focused on a single substance when abuse of multiple substancesis common, and follow-up periods have been relatively brief. A signifi-cant question concerning the effects of contingency management is thesustainability of the intervention over the long-term. At what point canmonetary incentives for sobriety be reduced or eliminated? Will the nat-urally occurring benefits of abstinence protect individuals from re-lapse? To what extent and how should contingency management becombined with other psychosocial interventions, such as skills trainingand relapse prevention?

Despite the many questions that remain, the positive results obtainedin the aforementioned studies are encouraging, and lend support to thepotential feasibility of using contingency-management interventionsalone or in combination with other treatments to reduce substance useamong dually-diagnosed clients. These data also support recent effortsto use disability income in a contingent manner to reduce substanceabuse among persons with severe mental illness (78, 89). For example,in a clinical trial in a dual-diagnosis clinic in Washington State clinicstaff serve as representative payees for clients who receive disability pay-ments (77). Case managers closely monitor clients’ clinical status, in-cluding substance abuse, mental status, and adherence to treatment. The

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proportion of disability payments that clients can use as discretionaryfunds increases as they demonstrate progress in these areas and an abilityto manage their finances responsibly. By using a representative payeewho can ensure that basic needs are met while dispensing additional flex-ibility in the use of those funds contingent on drug abstinence, contin-gency-management interventions could offer an effective approach toimproving quality of life and reducing substance abuse among individu-als with schizophrenia or other serious mental illness.

HOUSING INTERVENTIONS

Substance abuse adversely impacts stable housing for persons withdual disorders and is strongly associated with homelessness (20, 30,96). Clients who live in independent housing are particularly prone torelapses (105), and they appear to lose their housing due to several fac-tors, not only relapses but also financial problems, disruptive behaviors,and absences due to hospitalizations or incarcerations (29). Further-more, the provision of stable housing alone does not appear to reducesubstance abuse severity (83, 101). Therefore, integrated dual disorderand housing programs, or residential programs specifically tailored toaddress both mental health and substance abuse treatment needs, are in-creasingly common around the U.S. (56).

Research suggests that residential dual diagnosis programs that inte-grate and modify mental health and substance abuse treatment ap-proaches can be effective. We recently reviewed 10 controlled studiesof residential programs (1, 2, 9, 13, 15, 23, 50, 58, 72, 84). Our reviewshowed that successful programs were more integrated (blending men-tal health and substance abuse interventions), were more flexible (re-garding rules and automatic discharges), and planned for participants tostay longer (one year or more) in residence (14). For example, residen-tial programs with rigid boundaries had extremely high rates of non-en-try and early dropouts (9, 15, 23, 72).

Although there was some consistency in principles across these stud-ies, the programs varied widely in their models (e.g., self-help, rehabili-tation, cognitive-behavioral, modified therapeutic community, or amixture). There were no replications of the same model, and the modelsof these programs appeared to be evolving. All of these studies ad-dressed clients in the engagement and persuasion stages of treatment,often because they were designed for homeless persons. All of the stud-ies were quasi-experimental or experimental studies with serious

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methodologic problems, such as high cross-over (i.e., people in one res-idential program accessing services from another program) or attrition.The outcomes also varied considerably. Thus, the research suggests thatresidential programs are effective for clients who are highly unstablewith housing needs as well as with poor control of mental health andsubstance abuse problems. Yet a specific model has not emerged, andthere is no single well done experimental study of a dual diagnosis resi-dential program.

REHABILITATION INTERVENTIONS

Many studies as well as self-reports suggest that dual diagnosis cli-ents have difficulty attaining and sustaining substance abuse remissionswithout changing their lives considerably in terms of developing newrelationships and activities that do not involve substance use (31). Re-habilitation interventions to address social and vocational functioningare therefore often incorporated into dual diagnosis programs (62), butthere have been no studies of stand-alone rehabilitation interventions.The most relevant research in this area might be studies of supportedemployment, which often include many clients with co-occurring sub-stance abuse. These studies show that dually diagnosed clients benefitfrom supported employment programs more than from other vocationalapproaches (25, 86), and that they often, but not always (55), do as wellas non-substance abusing clients. Moreover, a majority of clients in along-term follow-up of supported employment reported that having ajob helped them to reduce substance abuse (85). However, there is asyet no experimental evidence that supported employment or getting ajob improves substance abuse outcomes.

DISCUSSION

The initial findings of controlled studies on the effects of specific in-terventions for persons with dual disorders are promising but as yet notscientifically convincing because of the lack of consistency and replica-tion. Despite the fact that a range of individual interventions are com-monly practiced, research focused on individual interventions has beenlimited to motivational enhancement strategies, with three (33, 51, 97)out of four (5) studies showing positive effects on substance abuse out-comes. These findings suggest that motivational interviewing has an

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important role to play in the early stages of dual diagnosis treatment, butunderscore the importance of evaluating individual treatment ap-proaches for the later stages of treatment, especially cognitive-behaviortherapy. Some work has been done in this regard by Barrowclough et al.(2001), who combined individual motivational interviewing and cogni-tive-behavior therapy with family intervention for clients with dual dis-orders.

Group interventions have been the most extensively studied treat-ment modality, and have garnered the most support for significant bene-fits. Among the seven studies comparing group intervention speciallytailored to persons with dual disorders to either no group treatment or12-step approaches, six (3, 10, 39, 47, 48, 103) found significant effectsin terms of either retention in services or substance abuse outcomes andone (54) did not. Two additional studies compared different models ofgroup intervention specially adapted to persons with dual disorders, andboth reported significant improvement in substance abuse and no groupdifferences (32, 76). Most of these studies of group intervention weregauged to clients’ at the early stages of treatment, mainly persuasion.However, the Lehman study, which involved a group focusing on sobri-ety, appears to have been geared to clients in later stages of treatment,and resulted in high rates of dropout. These studies suggest that groupinterventions employing a variety of different orientations can play akey role in helping clients move from the persuasion to the active treat-ment and relapse prevention stages, provided that the approach ad-dresses motivation early in treatment. Many of these studies employedstandardized manuals, but no replications of specific group interven-tions have been reported.

Interventions examining structural aspects of the treatment deliverysystem have found that more intensive integrated case managementapproaches produce modest benefits (and of questionable clinical signifi-cance) compared to less intensive interventions (26, 34). It appears thatmost clients with dual disorders do not require intensive case management.However, the slight advantages favoring more intensive treatment suggeststhat there may be a subgroup of individuals who benefit significantly morefrom that intervention. Identifying such a subgroup could improve match-ing treatment to individual needs.

The state of knowledge for other specific interventions for dual disor-ders is considerably less, largely owing to the paucity of methodologi-cally sound RCTs. No controlled trials of family intervention have beenpublished, although one study combining individual with family ther-apy reported promising results (6, 36). Similarly, only one RCT of con-

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tingency management has been completed (79), although severalrigorous within- subject design studies have demonstrated the feasibil-ity and promise of such approaches. A number of controlled interven-tions (mainly quasi- experimental) have addressed residential programs,with the general findings that longer-term programs adapted to personswith dual disorder can improve outcomes compared to standard resi-dential treatment for substance abuse (14). However, studies of residen-tial treatment program are especially replete with methodological problems,and retention even in integrated programs remains a problem. Last,studies of rehabilitation for persons with dual disorders have focusedmainly on supported employment, and have suggested that clients canbenefit from these interventions (86), although their effects on sub-stance abuse remain uncertain.

Studying specific interventions is difficult because most people proba-bly want and need multiple interventions and because the process of recov-ering from substance abuse is a long-term endeavor during which peoplehave many episodes of intervention. One useful strategy may be to isolateand examine individual interventions for short-term effects in clients whoare at a particular stage of treatment and for whom a particular outcome isimportant. Studies of motivational intervention or outreach to help with en-gagement are examples of this type of research. Similar strategies might besuccessful for clients at other stages. For example, contingency manage-ment could be studied as a method of initiating abstinence for clients in thepersuasion stage, cognitive-behavioral counseling might be appropriate forclients in the active treatment stage, and a relapse prevention group mightbe important for clients in the relapse prevention stage. Studies of relapseprevention seem particularly needed because most clients with dual disor-ders do relapse and there are currently so few studies addressing this prob-lem. Another strategy might be to target specific high-risk groups forparticular interventions. For example, clients who have post-traumaticstress disorder might be appropriate candidates for a PTSD intervention ora social networking intervention for women. Clients with poor cognitivefunctioning might be good candidates for residential programs that help toprovide external barriers to relapse.

Recovery from substance abuse, including sustained remission, is along-term proposition. Over the long run, maintaining people in one treat-ment or even in one complex treatment model is difficult. Drift inevitablyoccurs, and most clients will participate in multiple interventions. Wemight start with observational studies that determine which interven-tions people choose and find helpful, since the evidence suggests thatpeople who stay in treatment tend to do well. Longitudinal research is

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also critical for long-term disorders. At this point, we have little infor-mation on the long-term course of dual disorders. What strategies dopeople who are in remission use to prevent relapses? It would be impor-tant to know what proportion use self-help, group interventions, newfriendships, employment, cognitive strategies, and other supports tomaintain their remissions.

Considering the variety of different interventions for dual disordersthat are available, and the fact that preferences for specific interventionswill naturally vary across different clients, effectiveness studies maybenefit from considering alternative research designs to the standardRCT. In the standard RCT, clients are allowed to participate only if theyaccept randomization to any of the different treatment groups understudy. This can be problematic when more than two interventions arebeing investigated because if any intervention is unacceptable to the cli-ent, he or she cannot participate in the study. An alternative to this ap-proach is equipoise-stratified randomization (53), in which clients whoagree to randomization to at least two different interventions, but notnecessarily all the possible interventions under investigation, may par-ticipate in the study. This approach has advantages over standard RCTsin that it allows more clients to participate in research studies, therebyincreasing the generalization of findings to typical dual disorder treat-ment settings. In addition, equipoise-stratification results in treatmentgroup comparisons that are influenced by client preferences for specifictypes of treatment; statistical power is greatest for the comparison ofthose interventions that are most popular and acceptable to clients. Thisapproach could be used to compare different specific types of interventionsfor dual disorders, informed by naturalistic observation on which treat-ments are most likely to be used and by which clients.

Treatment of dual disorders has made significant progress over re-cent years, and there is growing consensus that the integration of mentalhealth and substance use services is critical to improved outcomes. Re-search focusing on specific interventions indicates promise for a varietyof approaches, but definitive support for none. Further work is neededto understand the role of specific interventions in the treatment of dualdisorders, and to replicate promising results of early research in thisarea. Despite the tentativeness of the empirical support for specifictreatments for dual disorders at this time, advances made thus far aresubstantial, and this progress bodes well for the future development andrefinement of interventions for this challenging population.

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REFERENCES

1. Aguilera, R., Anderson, A., Gabrie, E., Merlo, M., Paredes, T., & Pastrana, R. Aclinical impact evaluation of integrated and disease specific substance abuse programmodels in Honduras. International Journal of Psychosocial Rehabilitation, 1999;3:97-167.

2. Anderson, A. Comparative impact evaluation of two therapeutic programs formentally ill chemical abusers. International Journal of Psychosocial Rehabilitation,1999;4:11-26.

3. Aubrey, T., Cousins, B., LaFerriere, D., & Wexler, A. Evaluation of ConcurrentDisorders Group Treatment Program: Outcome Evaluation Report. Ottowa, Canada:Center for Research on Community Services, Faculty of Social Sciences, University ofOttowa. 2003.

4. Ayllon, T. The Token Economy: A Motivational System for Therapy and Reha-bilitation. New York: Appleton-Century-Crofts. 1968.

5. Baker, A., Lewin, T., Reichler, H., Clancy, R., Carr, V., Garrett, R., Sly, K.,Devir, H., & Terry, M. Motivational interviewing among psychiatric in-patients withsubstance use disorders. Acta Psychiatrica Scandinavica, 2002;106: 233-240.

6. Barrowclough, C., Haddock, G., Tarrier, N., Lewis, S., Moring, J., O’Brien, R.,Schofield, N., & McGovern, J. Randomized controlled trial of motivational interview-ing, cognitive behavior therapy, and family intervention for patients with comorbidschizophrenia and substance use disorders. American Journal of Psychiatry,2001;158:1706-1713.

7. Bellack, A. S., Mueser, K. T., Gingerich, S., & Agresta, J. Social Skills Trainingfor Schizophrenia: A Step-by-Step Guide (Second ed.). New York: Guilford Press.2004.

8. Bennett, M. E., Bellack, A. S., & Gearson, J. S. Treating substance abuse in schizo-phrenia: An initial report. Journal of Substance Abuse Treatment, 2001;20:163-175.

9. Blankertz, L. E., & Cnaan, R. A. Assessing the impact of two residential programsfor dually diagnosed homeless individuals. Social Service Review, 1994;68:536-560.

10. Bond, G., McDonel, E., Miller, L., & Pensec, M. Assertive community treat-ment and reference groups: An evaluation of their effectiveness for young adults withserious mental illness and substance abuse problems. Psychosocial RehabilitationJournal, 1991;15(2):31-43.

11. Brady, K. T., Killeen, T. K., Brewerton, T., & Lucerini, S. Comorbidity of psy-chiatric disorders and posttraumatic stress disorder. Journal of Clinical Psychiatry,2000;61 Suppl 7:22-32.

12. Breslau, N., Davis, G. C., & Schultz, L. R. Posttraumatic stress disorder and theincidence of nicotine, alcohol, and other drug disorders in persons who have experi-enced trauma. Archives of General Psychiatry, 2003;60:289-294.

13. Brunette, M. F., Drake, R. E., Woods, M., & Hartnett, T. A comparison oflong-term and short-term residential treatment programs for dual diagnosis patients.Psychiatric Services, 2001;52:526-528.

14. Brunette, M. F., Mueser, K. T., & Drake, R. E. A review of research on residen-tial programs for people with severe mental illness and co-occurring substance use dis-orders. Drug and Alcohol Review. (2004; 23: 471-481).

15. Burnam, M. A., Morton, S. C., McGlynn, E. A., Peterson, L. P., Stecher, B. M.,Hayes, C., & Vaccaro, J. V. An experimental evaluation of residential and nonresiden-

76 JOURNAL OF DUAL DIAGNOSIS

tial treatment for dually diagnosed homeless adults. Journal of Addictive Diseases,1995;14:111-134.

16. Carey, K. B., & Carey, M. P. Reasons for drinking among psychiatric outpa-tients: Relationship to drinking patterns. Psychology of Addictive Behaviors, 1995;9:251-257.

17. Carmichael, D., Tackett-Gibson, M., O’Dell, L., Jayasuria, B., Jordan, J., &Menon, R. Texas Dual Diagnosis Project Evaluation Report 1997-1998. College Sta-tion, TX: Public Policy Research Institute/Texas A&M University. 1998.

18. Caton, C. L. M. Mental health service use among homeless and never-homelessmen with schizophrenia. Psychiatric Services, 1995;46:1139-1143.

19. Caton, C. L. M., Shrout, P. E., Dominguez, B., Eagle, P. F., Opler, L. A., &Cournos, F. Risk factors for homelessness among women with schizophrenia. Ameri-can Journal of Public Health, 1995;85:1153-1156.

20. Center for Mental Health Services. Making a Difference: Interim Status Reportof the McKinney Research Demonstration Program for Homeless Mentally Ill Adults.Rockville, MD: SAMHSA. 1994.

21. Clark, R. E. Family support for persons with dual disorders. In R. E. Drake & K.T. Mueser (Eds.), Dual Diagnosis of Major Mental Illness and Substance Abuse Vol-ume 2: Recent Research and Clinical Implications. New Directions for Mental HealthServices (1996; Vol. 70:65-78). San Francisco: Jossey-Bass.

22. Clark, R. E. Family support and substance use outcomes for persons with mentalillness and substance use disorders. Schizophrenia Bulletin, 2001;27:93-101.

23. De Leon, G., Sacks, S., Staines, G., & McKendrick, K. Modified therapeuticcommunity for homeless mentally ill chemical abusers: Treatment outcomes. Ameri-can Journal of Drug and Alcohol Abuse, 2000;26:461-480.

24. Dixon, L., McFarlane, W., Lefley, H., Lucksted, A., Cohen, C., Falloon, I.,Mueser, K. T., Miklowitz, D., Solomon, P., & Sondheimer, D. Evidence-based prac-tices for services to family members of people with psychiatric disabilities. PsychiatricServices, 2001;52:903-910.

25. Drake, R. E., McHugo, G. J., Bebout, R. R., Becker, D. R., Harris, M., Bond, G. R.,& Quimby, E. A randomized clinical trial of supported employment for inner-city pa-tients with severe mental illness. Archives of General Psychiatry, 1999; 56:627-633.

26. Drake, R. E., McHugo, G. J., Clark, R. E., Teague, G. B., Xie, H., Miles, K., &Ackerson, T. H. Assertive community treatment for patients with co-occurring severemental illness and substance use disorder: A clinical trial. American Journal ofOrthopsychiatry, 1998;68:201-215.

27. Drake, R. E., Mercer-McFadden, C., Mueser, K. T., McHugo, G. J., & Bond, G.R. Review of integrated mental health and substance abuse treatment for patients withdual disorders. Schizophrenia Bulletin, 1998;24:589-608.

28. Drake, R. E., Mueser, K. T., Brunette, M. F., & McHugo, G. J. A review of treat-ments for clients with severe mental illness and co-occurring substance use disorder.Psychiatric Rehabilitation Journal, 2004;27:360-374.

29. Drake, R. E., Osher, F. C., & Wallach, M. A. Homelessness and dual diagnosis.American Psychologist, 1991;46:1149-1158.

30. Drake, R. E., Wallach, M. A., & Hoffman, J. S. Housing instability and home-lessness among aftercare patients of an urban state hospital. Hospital and CommunityPsychiatry, 1989;40:46-51.

Mueser et al. 77

31. Drake, R. E., Wallach, W. A., Alverson, H. S., & Mueser, K. T. Psychosocial as-pects of substance abuse by clients with severe mental illness. The Journal of Nervousand Mental Disease, 2002;190:100-106.

32. Drake, R. E., Yovetich, N. A., Bebout, R. R., Harris, M., & McHugo, G. J. Inte-grated treatment for dually diagnosed homeless adults. Journal of Nervous and MentalDisease, 1997;185:298-305.

33. Edwards, J., & McGorry, P. D. Implementing Early Intervention in Psychosis: AGuide to Establishing Early Psychosis Services. London: Martin Dunitz. 2002.

34. Godley, S. H., Hoewing-Roberson, R., & Godley, M. D. Final MISA Report.Bloomington, IL: Lighthouse Institute. 1994.

35. Graeber, D. A., Moyers, T. B., Griffith, G., Guajardo, E., & Tonigan, S. A pilotstudy comparing motivational interviewing and an educational intervention in patientswith schizophrenia and alcohol use disorders. Community Mental Health Journal,2003;39:189-202.

36. Haddock, G., Barrowclough, C., Tarrier, N., Moring, J., O’Brien, R., Schofield,N., Quinn, J., Palmer, S., Davies, L., Lowens, I., McGovern, J., & Lewis, S. Cogni-tive-behavioural therapy and motivational intervention for schizophrenia and sub-stance misuse: 18-month outcomes of a randomised controlled trial. British Journal ofPsychiatry, 2003;183:418-426.

37. Hamilton, T., & Sample, P. The Twelve Steps and Dual Recovery: A Frameworkof Recovery for Those of Us with Addiction and an Emotional or Psychiatric Illness.Center City, MN: Hazelden. 1994.

38. Harris, M. Trauma Recovery and Empowerment: A Clinician’s Guide for Work-ing With Women in Groups. New York: The Free Press. 1998.

39. Hellerstein, D. J., Rosenthal, R. N., & Miner, C. R. A prospective study of inte-grated outpatient treatment for substance-abusing schizophrenic outpatients. AmericanJournal on Addictions, 1995;4:33-42.

40. Higgins, S. T., Alessi, S. M., & Dantona, R. L. Voucher-based incentives: Asubstance abuse treatment innovation. Addictive Behaviors, 2002;27:887-910.

41. Higgins, S. T., Budney, A. J., Bickel, W. K., Foerg, F. E., Donham, R., &Badger, G. J. Incentives improve outcome in outpatient behavioral treatment of co-caine dependence. Archives of General Psychiatry, 1994;51:568-576.

42. Higgins, S. T., Delaney, D. D., Budney, A. J., Bickel, W. K., Hughes, J. R.,Foerg, F., & Fenwick, J. W. A behavioral approach to achieving initial cocaine absti-nence. American Journal of Psychiatry, 1991;148:1218-1224.

43. Higgins, S. T., & Silverman, K. Motivating Behavior Change Among Il-licit-Drug Abusers. Washington, DC: American Psychological Press. 1999.

44. Higgins, S. T., Wong, C. J., Badger, G. J., Haug-Ogden, D. E., & Dantona, R. L.Contingent reinforcement increases cocaine abstinence during outpatient treatmentand one year of follow-up. Journal of Consulting and Clinical Psychology,2000;68:64-72.

45. Ho, A. P., Tsuang, J. W., Liberman, R. P., Wang, R., Wilkins, J. N., Eckman, T.A., & Shaner, A. L. Achieving effective treatment of patients with chronic psychoticillness and comorbid substance dependence. American Journal of Psychiatry,1999;156:1765-1770.

46. Jacobson, L. K., Southwick, S. M., & Kosten, T. R. Substance use disorders inpatients with posttraumatic stress disorder: A review of the literature. American Jour-nal of Psychiatry, 2001;158:1184-1190.

78 JOURNAL OF DUAL DIAGNOSIS

47. James, W., Preston, N. J., Koh, G., Spencer, C., Kisely, S. R., & Castle, D. J. Agroup intervention which assists patients with dual diagnosis reduce their drug use: Arandomised controlled trial. Psychological Medicine. (2004; 34:983-990).

48. Jerrell, J. M. Cost-effective treatment for persons with dual disorder. In R. E.Drake & K. T. Mueser (Eds.), Dual Diagnosis of Major Mental Illness and SubstanceAbuse Volume 2: Recent Research and Clinical Implications. New Directions for Men-tal Health Services (1996; Vol.70: 79-91). San Francisco, CA: Jossey-Bass.

49. Jerrell, J. M., & Ridgely, M. S. Comparative effectiveness of three approachesto serving people with severe mental illness and substance use disorders. Journal ofNervous and Mental Disease, 1995;183:566-576.

50. Kasprow, W. J., Rosenheck, R., Frisman, L., & DiLella, D. Residential treat-ment for dually diagnosed homeless veterans: A comparison of program types. Ameri-can Journal on Addiction, 1999;8:34-43.

51. Kavanagh, D. J., Young, R., White, A., Saunders, J. B., Wallis, J., Shocklewy,N., Jenner, L., & Clair, A. A brief motivational intervention for substance misuse in re-cent-onset psychosis. Drug and Alcohol Review. (2004; 23:151-155).

52. Laudet, A. B., Magura, S., Vogel, H. S., & Knight, E. Addiction services: Sup-port, mutual aid and recovery from dual diagnosis. Community Mental Health Journal,2000;36:457-476.

53. Lavori, P. W., Rush, A. J., Wisniewski, S. R., Alpert, J., Fava, M., Kupfer, D. J.,Nierenberg, A., Quitkin, F. M., Sackeim, H. A., Thase, M. E., & Trivedi, M. Strength-ening clinical effectiveness trials: Equipoise-stratified randomization. Biological Psy-chiatry, 2001;50:792-801.

54. Lehman, A., Herron, J., Schwartz, R., & Myers, C. Rehabilitation for adultswith severe mental illness and substance use disorders: A clinical trial. Journal of Ner-vous and Mental Disease, 1993;181:86-90.

55. Lehman, A. F., Goldberg, R., Dixon, L. B., McNary, S., Postrado, L., Hackman,A., & McDonnell, K. Improving employment outcomes for persons with severe mentalillnesses. Archives of General Psychiatry, 2002;59:165-172.

56. McCoy, M. L., Devitt, T., Clay, R., Davis, K. E., Dincin, J., Pavick, D., &O’Neill, S. C. Gaining insight: Who benefits from residential, integrated treatment forpeople with dual diagnoses. Psychiatric Rehabilitation Journal, 2003;27:140-150.

57. Miller, W. R., & Wilbourne, P. L. Mesa Grande: A methodological analysis ofclinical trials of treatments for alcohol use disorders. Addiction, 2002;97:265-277.

58. Moggi, F., Hirsbrunner, H.-P., Brodbeck, J., & Bachmann, K. M. One-year out-come of an integrative inpatient treatment for dual diagnosis patients. Addictive Behav-iors, 1999;24:589-592.

59. Moos, R., Schaefer, J. J., Andassy, J., & Moos, B. Outpatient mental health care,self-help groups, and patients’ one-year outcomes. Journal of Clinical Psychology,2001;57:273-287.

60. Mueser, K. T., & Fox, L. A family intervention program for dual disorders.Community Mental Health Journal, 2002;38:253-270.

61. Mueser, K. T., Nishith, P., Tracy, J. I., DeGirolamo, J., & Molinaro, M. Expec-tations and motives for substance use in schizophrenia. Schizophrenia Bulletin,1995;21:367-378.

62. Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. Integrated Treatment forDual Disorders: A Guide to Effective Practice. New York: Guilford Press. 2003.

Mueser et al. 79

63. Mueser, K. T., Rosenberg, S. D., Goodman, L. A., & Trumbetta, S. L. Trauma,PTSD, and the course of schizophrenia: An interactive model. Schizophrenia Re-search, 2002;53:123-143.

64. Mueser, K. T., Rosenberg, S. D., Jankowski, M. K., Hamblen, J., & Descamps,M. A cognitive-behavioral treatment program for posttraumatic stress disorder in se-vere mental illness. American Journal of Psychiatric Rehabilitation. (2004; 7:107-146).

65. Mueser, K. T., Salyers, M. P., Rosenberg, S. D., Goodman, L. A., Essock, S. M.,Osher, F. C., Swartz, M. S., & Butterfield, M. Interpersonal trauma and posttraumaticstress disorder in patients with severe mental illness: Demographic, clinical, and healthcorrelates. Schizophrenia Bulletin, 2004;30:45-57.

66. Muijen, M., Holloway, F., & Goldman, H. Mental health services. In S. R.Hirsch & D. F. Weinberger (Eds.), Schizophrenia (Second ed., pp. 688-700). Oxford:Blackwell. 2003.

67. Najavits, L. M. Seeking Safety: A Treatment Manual for PTSD and SubstanceAbuse. New York: Guilford Publications. 2002.

68. Nishith, P., Resick, P. A., & Mueser, K. T. Sleep disturbances and alcohol usemotives in female rape victims with posttraumatic stress disorder. Journal of Trau-matic Stress, 2001;14:469-479.

69. Noordsy, D. L., Drake, R. E., Biesanz, J. C., & McHugo, G. J. Family history ofalcoholism in schizophrenia. Journal of Nervous and Mental Disease, 1994;186:651-655.

70. Noordsy, D. L., Drake, R. E., Teague, G. B., Osher, F. C., Hurlbut, S. C.,Beaudett, M. S., & Paskus, T. S. Subjective experiences related to alcohol abuse amongschizophrenics. Journal of Nervous and Mental Disease, 1991;179:410-414.

71. Noordsy, D. L., Schwab, B., Fox, L., & Drake, R. E. The role of self-help pro-grams in the rehabilitation of persons with severe mental illness and substance use dis-orders. Community Mental Health Journal, 1996;32:71-81.

72. Nuttbrock, L. A., Rahav, M., Rivera, J. J., Ny-Mak, D. S., & Link, B. G. Out-comes of homeless mentally ill chemical abusers in community residences and a thera-peutic community. Psychiatric Services, 1998;49(1):68-76.

73. Osher, F. C., & Kofoed, L. L. Treatment of patients with psychiatric and psy-choactive substance use disorders. Hospital and Community Psychiatry, 1989;40:1025-1030.

74. Paul, G. L., & Lentz, R. J. Psychosocial Treatment of Chronic Mental Patients:Milieu versus Social-Learning Programs. Cambridge, MA: Harvard University Press.1977.

75. Peniston, E. G. Evaluation of long-term therapeutic efficacy of behavior modi-fication program with chronic male psychiatric inpatients. Journal of Behavior Ther-apy and Experimental Psychiatry, 1988;19:95-101.

76. Penn, P. E., & Brooks, A. J. Comparing Substance Abuse Treatments for DualDiagnosis: Final Report. Tucson, AZ: La Frontera Center, Inc. 1999.

77. Ries, R. K., & Comtois, K. A. Managing disability benefits as part of treatmentfor persons with severe mental illness and comorbid drug/alcohol disorders: A compar-ative study of payees and non-payee participants. American Journal on Addictions,1997;6:330-338.

78. Ries, R. K., & Dyck, D. G. Representative payee practices of community mentalhealth centers in Washington state. Psychiatric Services, 1997;48:811-814.

80 JOURNAL OF DUAL DIAGNOSIS

79. Ries, R. K., Dyck, D. G., Short, R., Srebnik, D., Fisher, A., & Comtois, K. A.Outcomes of managing disability benefits among patients with substance dependenceand severe mental illness. Psychiatric Services, 2004;55:445-447.

80. Roberts, L. J., Shaner, A., & Eckman, T. A. Overcoming Addictions: SkillsTraining for People with Schizophrenia. New York: W.W. Norton. 1999.

81. Roll, J. M., Chermack, S. T., & Chudzynski, J. E. Investigating the use of con-tingency management in the treatment of cocaine abuse among individuals withschizophrenia: A feasibility study. Psychiatry Research, 2004;125:61-64.

82. Roll, J. M., Higgins, S. T., Steingard, S., & McGinley, M. Use of monetary rein-forcement to reduce the cigarette smoking of persons with schizophrenia: A feasibilitystudy. Experimental and Clinical Psychopharmacology, 1998;6:142-161.

83. Sacks, J. A., Drake, R. E., Williams, V. F., Banks, S. M., & Herrell, J. M. Utilityof the Time-Line Follow-Back to assess substance use among homeless adults. Journalof Nervous and Mental Disease, 2003;191:145-153.

84. Sacks, S., & Sacks, J. Y. et al. Modified therapeutic community for MICA of-fenders: Crime outcomes. Behavioral Sciences & the Law. (2004; 22: 477-501).

85. Salyers, M. P., Becker, D. R., Drake, R. E., Torrey, W. C., & Wyzik, P. Aten-year follow-up of a supported employment program. Psychiatric Services,2004;55:302-308.

86. Sengupta, A., Drake, R. E., & McHugo, G. J. The relationship between sub-stance use disorder and vocational functioning among persons with severe mental ill-ness. Psychiatric Rehabilitation Journal, 1998;22:41-45.

87. Shaner, A., Eckman, T. A., Roberts, L. J., Wilkins, J. N., Tucker, D. E., Tsuang,J. W., & Mintz, J. Disability income, cocaine use, and repeated hospitalization amongschizophrenic cocaine abusers. The New England Journal of Medicine, 1995;333:777-783.

88. Shaner, A., Roberts, L. J., Eckman, T. A., Tucker, D. E., Tsuang, J. W., Wilkins,J. N., & Mintz, J. Monetary reinforcement of abstinence from cocaine among mentallyill patients with cocaine dependence. Psychiatric Services, 1997;48:807-810.

89. Shaner, A., Tucker, D. E., Roberts, L. J., & Eckman, T. A. Disability income,cocaine use, and contingency management among patients with cocaine dependenceand schizophrenia. In S. T. Higgins & K. Silverman (Eds.), Motivating BehaviorChange Among Illicit-Drug Abusers (1999: pp. 95-121). Washington, DC: AmericanPsychological Association.

90. Sigmon, S. C., & Higgins, S. T. Voucher-based contingent reinforcement ofmarijuana abstinence among individuals with serious mental illness. (in preparation).

91. Sigmon, S. C., Steingard, S., Badger, G. J., Anthony, S. L., & Higgins, S. T.Contingent reinforcement of marijuana abstinence among individuals with seriousmental illness: A feasibility study. Experimental and Clinical Psychopharmacology,2000;8:509-517.

92. Simpson, D. D., Joe, G. W., & Brown, B. S. Treatment retention and follow-upoutcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Ad-dictive Behaviors, 1996;11:294-307.

93. Simpson, D. D., Joe, G. W., Lehman, W. E. K., & Sells, S. B. Addiction careers:Etiology, treatment, and 12 year follow-up procedures. Journal of Drug Issues,1986;16:107-121.

94. Stanton, M. D., & Shadish, W. R. Outcome, attrition, and family-couples treat-ment for drug abuse: A meta-analysis and review of the controlled, comparative stud-ies. Psychological Bulletin, 1997;122:170-191.

Mueser et al. 81

95. Stein, L. I., & Santos, A. B. Assertive Community Treatment of Persons with Se-vere Mental Illness. New York: Norton. 1998.

96. Susser, E., Struening, E. L., & Conover, S. Psychiatric problems in homelessmen: Lifetime psychosis, substance use, and current distress in new arrivals at NewYork City shelters. Archives of General Psychiatry, 1989;46:845-850.

97. Swanson, A. J., Pantalon, M. V., & Cohen, K. R. Motivational interviewing andtreatment adherence among psychiatric and dually diagnosed patients. Journal of Ner-vous and Mental Disease, 1999;187:630-635.

98. Switzer, G. E., Dew, M. A., Thompson, K., Goycoolea, J. M., Derricott, T., &Mullins, S. D. Posttraumatic stress disorder and service utilization among urban mentalhealth center clients. Journal of Traumatic Stress, 1999;12:25-39.

99. Tidey, J. W., O’Neill, S. C., & Higgins, S. T. Contingent monetary reinforce-ment of smoking reductions, with and without transdermal nicotine, in outpatients withschizophrenia. Experimental and Clinical Pharmacology, 2002;10:241-247.

100. Trumbetta, S. L., Mueser, K. T., Quimby, E., Bebout, R., & Teague, G. B. Socialnetworks and clinical outcomes of dually diagnosed homeless persons. Behavior Ther-apy, 1999;30:407-430.

101. Tsemberis, S., Gulcur, L., & Nakae, M. Housing first, consumer choice, andharm reduction for homeless individuals with a dual diagnosis. American Journal ofPublic Health, 2004;94:651-656.

102. Vogel, H. S., Knight, E., Laudet, A. B., & Magura, S. Double Trouble in Recov-ery: Self-help for the dually diagnosed. Psychiatric Rehabilitation Journal,1998;21:356-364.

103. Weiss, R. D., Griffin, M. L., Greenfield, S. F., Najavits, L. M., Wyner, D., Soto,J. A., & Hennen, J. A. Group therapy for patients with bipolar and substance depend-ence: Results of a pilot study. Journal of Clinical Psychiatry, 2000;61:361-367.

104. Westermeyer, J., Myott, S., Aarts, R., & Thuras, P. Self-help strategies amongpatients with substance use disorders. American Journal on Addictions, 2001;10:249-257.

105. Xie, H., McHugo, G. J., & Drake, R. E. Substance abuse relapses in a 10-yearfollow-up of clients with severe mental disorders and co-occurring substance use dis-orders. (submitted).

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