Book Review
Substance Abuse 
Integrated Treatment for Dual Disorders. A Guide to Effective Practice. Kim T Mueser, Douglas L Noordsy, Robert E Drake, Lindy Fox. New York: The Guilford Press; 2003. 470 p. US$42.00.
Reviewer
rating*: Excellent
Review by: Maurice Dongier, MD, FRCPC
Montreal, Quebec
The cooccurrence of substance abuse and severe mental illness (which is how these authors define dual disorders) is a frequent problem in psychiatry and one that is associated with poorer outcome. Substance abuse has a strong impact on psychiatric illness: alcohol abuse increases the risk of suicide among depression, schizophrenia, and bipolar disorder patients; use of cannabis and other illicit drugs contributes to treatment resistance and poor adherence, as well as to many relapses and hospitalizations, in all major psychotic disorders. In the general population, the lifetime prevalence of substance abuse disorders (SAD) is 16.7%. However, among schizophrenia patients, it is 47%; among those with major depression, it is 27%; and among bipolar disorder patients, it is 56%. Of the SADs, alcohol abuse is the most common, followed by cannabis and cocaine abuse. Spontaneous remission without treatment is much rarer than in the general population.
The traditional approach is to treat first the primary disorder, then the secondary one. Sometimes, simultaneous treatment occurs (that is, parallel treatment by different clinics or agencies). Lack of coordination leads regularly to poor prognosis.
This comprehensive textbook summarizes 20 years of clinical research efforts and proposes an alternative. The authors are psychologists and psychiatrists who all belong to the well-known team of the New Hampshire–Dartmouth Psychiatric Research Centre. This centre has been at the forefront of research and enjoys undisputed leadership in integrating intervention strategies for SAD and its associated mental disorders. For the past 2 decades, this group has refined the following principles: proactive and empathic outreach, continuity of care, optimism, stage-specific treatment, and education and engagement of family members. The intervention’s core philosophy is to replace exclusion with inclusion. For example, clients who present to a group session under the influence of alcohol or drugs are not automatically excluded from participating, as long as their behaviour is not disruptive—in contrast to the policies of most group therapies for substance abuse. Typically, their presence elicits powerful responses from group members.
The book’s strengths are numerous. It emphasizes shared decision making, in that clients and families are involved in treatment planning. This maximizes the chances of compliance and long-term follow-up. Importantly, the decision between abstinence and harm reduction (that is, controlled consumption) must come from the client. The book offers a menu of treatment options (for example, Alcoholics Anonymous, residential programs, brief interventions, cognitive-behavioural therapies [CBTs], assertive community treatment, and supported employment). Relapses, which are to be expected in both components of the dual disorder, are not viewed as failures but as occasions to benefit from new experiences. The book espouses the general spirit of motivational interviewing (MI) as developed by Miller and Rollnick, with acknowledgement and respect for the client’s resistance to change (for example, in substance abuse behaviour or in medication compliance) and avoidance of confrontation. It details individual and group interventions that include MI, cognitive-behavioural counselling, working with families, and assessment instruments; 120 pages out of 470 are devoted to useful appendices offering checklists of the most important ingredients, treatment-fidelity scales, scoring sheets, and educational handouts for various types of disorders. The book describes the assessment process in great detail and suggests an excellent selection of instruments. It provides solid evidence (for example, controlled studies with follow-up periods extending from 1 to 3 years) to support long-term integrated treatment. Finally, it has excellent clinical examples of individual dual disorder treatment plans. Chapter 6 on stagewise case management (specifically, engagement, persuasion, active treatment, and relapse prevention) is particularly well done and enlightening. It is informed by the assertive care therapy (ACT) model (comprising outreach, team work, and direct rather than brokered service delivery), which it describes in detail and clearly summarizes in tables.
The book’s weaknesses may be paradoxically related to its excellence and high standards, in that they contrast with the limitations imposed by lack of resources observed in the real world. For example, the basic approach to training the staff of a new program (see p 40) is so demanding that few existing programs can probably meet expectations, as witnessed by the following excerpt:
The outmoded practice of referring clients with suspected substance abuse to a specialist for assessment frequently results in cases being missed . . . . Furthermore, substance abuse usually does not occur in single or discrete episodes; it is a chronic relapsing condition that requires ongoing management . . . therefore all clinicians need to master certain basic skills including assessment (chapters 4 and 5), MI (chapter 7) and cognitive behavioural abuse counselling (chapter 8, p 39).
Further, multimodal intervention is the rule: individual, group, and family approaches are integrated. The impact of each individual component is unknown, and it is somewhat frustrating to be left in doubt about the relative importance of each ingredient. My own guess would be that ACT, conducted long-term and within the spirit of MI, would probably be most significant in most cases.
In conclusion, the New Hampshire team proposes a program built over the past 2 decades, with fair empirical support for its superiority. How widely has it spread over the US, Canada, and elsewhere? I don’t know the answer to this question, but my guess is that it has not been taken up as much as one would hope, for the following reasons: 1) psychiatrists in general, many of whom receive inadequate substance abuse training in their residency programs, have limited interest in this area; 2) in the US, the context of managed care is a factor; and 3) in Canada and Europe, the vagaries of financing the health care system are factors. These issues are not conducive to the major changes required by the proposed philosophy.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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