Hospital and Community Psychiatry October 1989 Vol. 40 No. 10 .docx

Hospital and Community Psychiatry October 1989 Vol. 40 No.
10 1025
dictive Behaviors. Edited by Donovan
DM, Marlart GA. New York, Guilford,
1988
35. Grant I, Reed R: Neuropsychology of
alcohol and drug abuse, in Substance
Abuse and Psychology. Edited by Alter-
man A!. NewYork, Plenum, 1985
36. Vardy MM, Kay SR: LSD psychosis or
LSD-induced schizophrenia? A multi-
method inquiry. Archives of General
Psychiatry 40:877-883, 1983
37. Castellani 5, Petnie WM, Ellinwood E:
Drug-induced psychosis: neurobiologi-
cal mechanisms, in Substance Abuse and
Psychology. Edited by Alterman A!.
New York, Plenum, 1985
38. McLellan AT, Woody GE, O’Brien CP:
Development ofpsychiatnic disorders in
drug abusers. New England Journal of
Medicine 301:1310-1314, 1979

39. Ellinwood E, Duarte-Escalante 0:
Chronic methamphetamine intoxication
in three species ofexperimental animals,
in Current Concepts on Amphetamine
Abuse. Edited by Ellinwood E, Cohen S.
Rockville, Md, National Institute of
Mental Health, 1972
40. BeIIDS: The experimental reproduction
of amphetamine psychosis. Archives of
General Psychiatry 30:35-40, 1973
41. Alterman A!: Substance abuse in psychi-
atnic patients, in Substance Abuse and
42. Kendler KS: A twin study of individuals
with both schizophrenia and alcoholism.
BritishJournal ofPsychiatry 147:48-53,
1985
43. Hesselbrock MN, Hesselbrock VM,
Tennen H, et al: Methodological con-
sidenations in the assessment of depres-
sion in alcoholics. Journal of Consulting
and Clinical Psychology 51:399-405,

1983
44. HimmelhochJM, Hill 5, Steunberg B, et
al: Lithium, alcoholism, and psychiatric
diagnosis. Journal of Psychiatric Treat-
ment and Evaluation 5:83-88, 1983
45. Mayfield D: Substance abuse in theaffec-
sive disorders, in Substance Abuse and
46. Schuckit MA: The importance of family
history ofaffective disorder in agroup of
young men. Journal of Nervous and
MentalDisease 170:530-535, 1982
47. Robertson MJ: Mental disorder among
homeless persons in the United States:
an overview of recent empirical liters-
tare. Administration in Mental Health
14:14-27, 1986
48. Blashfield BK Propositions regarding
the use of cluster analysis in clinical re-
search.JournalofConsultingand Clinical
Psychology 48:456-459, 1980

49. Blashfield RK, Money LC:The classifica-
tion of depression through cluster anal-
ysis. Comprehensive Psychiatry 20:516-
527, 1979
50. OverallJE, Hollister LE, Johnson M, et
al: Nosology ofdepression and differen-
tial response to drugs. JAMA 195:946-
948, 1966
51. Spitzer RL, Williams JBW: Having a
dream: a research study for DSM-IV.
Archives ofGeneral Psychiatry 45:871-
874, 1988
Treatment of Patients With
Psychiatric and Psychoactive
Substance Abuse Disorders
Fred C. Osher, M.D.
Lial L. Kofoed, M.D.
The treatment ofindividuals with
coexisting psychoactive substance
abuse and severepsychiatric disor-
ders requires an integration of
principles from the mental health
and chemical dependency fields.

The authors outline a conceptual
model for treating dually diag-
nosedpatients that consists offour
treatment phases-engagement,
persuasion, active (or primary)
treatment, and relapse prevention.
The components of these phases
include case management, group
therapy, psychopharmacology,
toxicologic screening, detoxifica-
tion,family involvement, and par-
ticipation in self-help groups. Due
to the high morbidity and mor-
tality associated with dual diag-
noses, the authors encourage the
development, implementation,
and scientific evaluation of in-
tegrated treatment models tar-
geted toward this population.
The consequences ofcoexisting psy-
chiatric and psychoactive substance
use disorders can be devastating, yet
few studies have assessed the treat-
ment ofthis dually diagnosed patient
population. Compared with either
mentally ill or chemically dependent
patients, dually diagnosed patients
demonstrate increased rates of hos-

pitalization ( 1), utilization of acute
care services (2), housing instability
and homelessness (3-5), violent and
criminal behavior ( 1 ,6), and suicidal
behavior (3,7).
Poor medication compliance
(3,8) and poor response to tradition-
al substance abuse treatment (9,10)
have also been associated with
having dual disorders. Despite, and
perhaps because of, the severe ef-
fects of such comorbidity, dually
diagnosed patients are often ex-
cluded from treatment settings.
Dual diagnosis patients are het-
erogeneous in the psychiatric diag-
noses they receive (1 1, 12), the sub-
stances they abuse (6,1 1), and the
degree of dysfunction they show
(13). Both symptom severity (10)
and psychiatric diagnosis (14,15)
have been found to predict treat-
ment response of patients with sub-
stance use disorders.
Among nonpsychotic patients
with dual diagnoses, a diagnosis of
personality disorder, especially anti-
social personality disorder, has been
associated with adverse outcome
(14-17). Improved outcome for

1026 October 1989 Vol. 40 No. 10 Hospital and Community
Psychiatry
these patients when significant
symptoms of anxiety or depression
are present has resulted from adding
psychotherapy to substance abuse
counseling (16). The treatment of
patients with primary affective and
anxiety disorders and substance use
disorders remains controversial.
Recent reviews by Galanter and as-
sociates ( 1 8) and Bloom and as-
sociates (19) address issues in the
treatment of nonpsychotic patients
within the dual-diagnosis popula-
tion.
This paper reflects our exper-
ience treating patients with severe,
chronic, or recurrent axis I psychiat-
tic disorders, including schizophren-
ia and bipolar affective disorder,
who also abuse psychoactive sub-
stances. We outline a conceptual
model for treating such patients that
emphasizes four phases of treat-
ment: engagement, persuasion, ac-
tive (or primary) treatment, and
relapse prevention. The treatment
recommendations represent a syn-
thesis of our clinical experience and
the scant available literature. We en-
courage clinical research to further
validate this model and other ap-

proaches to integrated treatment of
patients with psychiatric and sub-
stance abuse disorders.
Treatment overview
Integrated treatment. Treatment
approaches for dually diagnosed pa-
tients thatprovide mental health and
substance abuse interventions se-
Dr. Osher is staff psychiatrist at
West Central Community Mental
Health Services in Hanover, New
Hampshire. Dr. Kofoed is direc-
tor of outpatient services at the
Veterans Administration Medi-
cal Center in White River Junc-
tion, Vermont. Dr. Osher is also
assistantprofessor andDr. Kofoed
is associate professor in the
department ofpsychiatry at Dart-
mouth Medical School in Han-
over. Address correspondence to
Dr. Osher at 18 Bailey Avenue,
Claremont, New Hampshire
03743. This paper is part of a spe-
cia! section on patients with dual
diagnoses of mental illness and
substance abuse.
quentially result in a sort of “Ping-
Pong therapy” that maygive patients
conflicting messages and little
chance of compliance with both

treatment plans. Parallel treatment
ofboth disorders in separate systems
has similar limitations.
We advocate the integration of
existing mental health and chemical
dependency approaches for treating
dually diagnosed patients (20). Such
approaches have demonstrated
some efficacy (1 7,2 1). They require
ongoing attention to both disorders
and a synthesis of treatment prin-
ciples. They also allow clinicians to
monitor multiple problems and
prioritize treatment goals. In devel-
oping the model we present in this
paper, our aim was to respond to the
needs ofpatients with severe psychi-
atric illnesses. Therefore, the model
we describe integrates substance
abuse treatment into a mental health
agency setting.
Treatment setting. The rela-
tive value ofinpatient and outpatient
treatment settings for dually diag-
nosed patients remains to be deter-
mined, a state of affairs also largely
true for treatment of primary sub-
stance abusers. Outpatient treat-
ment forvery ill dually diagnosed pa-
tients has been described (17,2 1).

However, assessment of the con-
tributions of psychiatric illness and
substance abuse to patients’ clinical
presentations may require observa-
iion within a controlled environ-
ment. Access to brief psychiatric
hospitalization is therefore essential.
Appropriate goals for such hospital-
izations include detoxification, diag-
nostic clarification, stabilization of
the patient, and adjustment of
medications. In addition, hospital-
ization provides an opportunity to
persuade the patient to accept reha-
bilitative treatment (22,2 3).
Substances ofabuse. Except in
programs focused on special modal-
ities such as methadone mainte-
nance, primary abusers of alcohol
and of a variety of drugs can be
treated in the same program with lit-
tIe reduction in efficacy (24). On the
other hand, one study ofdually diag-
nosed patients found worse out-
comes among patients who abused
alcohol than among patients who
abused drugs when the two groups
were treated together, although
these patients differed on other van-
ables besides substance of abuse
(17). Further research into the need
for substance-specific treatment

programming is required.
Polysubstance abuse is frequently
reported in the dual-diagnosis pop-
ulation (3,20,25). Clinicians work-
ing with this population must be
prepared to provide treatment for
the abuse ofa wide range of psycho-
active substances.
Treatment phases
Patients joining an integrated treat-
ment program are likely to be in dif-
ferent phases ofillness and recovery,
given the chronic relapsing course of
severe psychiatric and addictive dis-
orders, the variation in individuals’
ability to form treatment relation-
ships (1 7,26), and differences in pre-
vious exposure to treatment. Treat-
ment goals should reflect this van-
ability. For instance, abstinence is
not a feasible goal until the patient
has acknowledged substance abuse
as a problem. Relapse prevention
cannot be taught before a period of
sobriety.
The four phases described below
differentiate patients on the basis of
their commitment to substance
abuse treatment, yet are also depen-
dent on the management and stabil-
ization oftheir psychiatric disorder.
Engagement

Dually diagnosed individuals must
first be attracted to treatment pro-
grams. Engagement denotes the pro-
cess of convincing patients that the
mental health agency or provider has
something desirable to offer them.
Enticements may include help in
avoiding legal penalties or in obtain-
ing food, housing, clothing, access to
entidement programs, or relief from
distressing symptoms. Socialization,
recreation, and vocational oppor-
tunities may also provide incentives
for participation in treatment. Iso-
lated on homeless patients often re-
quire assertive outreach, help with
basic needs, and support during
crises (27).
Engagement can also be accom-
plished indirectly by staff liaison
with family members or coercively
10 1027
through public guardians or the
criminal justice system. The courts
may defer sentencing of convicted
patients who participate in treat-
ment or may require that patients
receive treatment as a condition of
discharge after involuntary commit-
ment. Coercive treatment has been

associated with improved treatment
retention in difficult dually diag-
nosed patients (17,19).
Persuasion
Persuasion is the process of convinc-
ing engaged patients to accept long-
term abstinence-oriented treatment
(23,28,29). Accomplishing this
phase of treatment is difficult for
several reasons. First, patients who
are unemployed or disaffiliated may
escape social pressures that often in-
duce other substance abusers to seek
treatment. Second, dually diagnosed
patients, and sometimes their thera-
pists, may excuse their substance use
as secondary to their psychiatric dis-
orders. Finally and perhaps most im-
portant, patients’ impaired ability to
process information due to thought
disorder, depressive cognition, or
organic brain syndromes com-
promises their ability to transcend
denial (23), a core part of all sub-
stance abuse syndromes (28,30).
While clinicians often view pa-
tients’ motivation as a trait rather
than a state, a variety of interven-
tions may improve treatment accep-
tance and retention. These modal-
ities range from focused psychother-
apies (17,31) to prerehabilitative
groups (23,29,32). The basic prin-
ciples ofpersuasion apply to all these

activities (28). Clinicians should be
clear and consistent in presenting
diagnoses and their treatment im-
plications. Discussion of objective
data, such Breathalyzer or urine test
results, abnormal laboratory or phy-
sical findings, psychiatric symptoms,
and social or legal difficulties related
to substance abuse, can help per-
suade patients to accept treatment.
Hospitalization presents an excel-
lent opportunity to persuade dually
diagnosed patients that they need
substance abuse treatment. In-
patients have in some way acknowl-
edged their distress, are more likely
to be abstinent, are already in the
patient role, and have credible peers
available on the ward. Their psychi-
attic disorder may be relatively stabi-
lized. In these circumstances, group
therapy focused on persuasion has
shown moderate effectiveness in
moving patients toward acceptance
ofsubstance abuse intervention (23).
During the persuasion phase, cli-
nicians should focus their attention
on the overall readiness of patients
to commit themselves to treatment.
A patient’s premature commitment
to behavioral change involving sub-

stance use may lead to a sense of
frustration or failure. For patients
who acknowledge the need for treat-
ment, assurances ofongoing support
despite early lapses must be explicit.
Active treatment
Active, or primary, treatment is fo-
cused on helping patients develop
the attitudes and skills necessary to
remain sober. A range of behavioral,
psychoeducational, and medical in-
terventions may be offered, al-
though no studies have yet com-
pared specific program components.
The type and timing of interventions
can be determined only by clinical
assessment ofindividual patients’ ill-
nesses and needs.
Prolonged abstinence is difficult
for the dually diagnosed patient. Un-
fortunately, some treatment pro-
grams lower their expectations of
dually diagnosed patients, accept
reduced substance use as a goal, or
tolerate frequent relapse as inevi-
table. However, dually diagnosed
patients are likely to suffer worse
consequences with relapse than
primary substance abusers. Some
data suggest that negative conse-
quences for the dually diagnosed

patient can occur at relatively low
levels of alcohol or illicit drug use
(3). In addition, treatment programs
that accept goals other than
abstinence may contribute to pa-
tients’ exclusion from self-help
groups such as Alcoholics Anony-
mous (AA), which may be a valuable
resource for helping dually diag-
nosed patients maintain sobriety
(17,2 1).
It is important for programs to es-
tablish a culture of abstinence as an
integral part of their therapeutic
milieu. Contracts with contingencies
that stipulate the consequences of
lapses may help formalize patients’
commitment to change. In the
authors’ experience, such contracts
have been useful in the early phases
oftreatment. Despite temporary set-
backs, high expectations for patients’
ability to end their addiction should
be maintained if patients are to re-
main hopeful.
Relapse prevention
Abstinence is not the end of sub-
stance abuse treatment for the dually
diagnosed patient. Most of the van-
ance in long-term outcomes of pri-
mary substance abuse treatment can
be accounted for by events that
transpire after active treatment and

the initial cessation of substance
abuse (33). Maintenance requires an
ongoing connection between the
patient and trusted health care
providers. During this phase of treat-
ment, the clinician should point out
the patient’s successes but should
also monitor the patient for pro-
dromes to relapse.
Lapses or “slips” following absti-
nence are to be anticipated. The pa-
tient’s cognitive and affective re-
sponses to these lapses may deter-
mine the degree to which the patient
will return to his former behavior
(34). Both the clinician’s and the
patient’s anticipated responses to
lapses should be discussed before
they occur. Relapse can be a learning
experience. The discovery and rapid
arrest ofiitial lapses may help in the
prevention oflater ones.
Progression through these phases
may take a considerable amount of
time for individual patients. Patients
may regress to earlierphases because
of changes in addictive behavior or
ambivalent commitment to treat-
ment goals. Clinicians need peer
support and insightful supervision to
maintain a positive attitude toward
the dually diagnosed patient. At-
tending Al-Anon meetings may help

the clinician maintain a balanced re-
lationship with the patient.
Treatment components
The integration of substance abuse
treatment into mental health settings
involves a broad range of specialized
services. The following sections de-
scribe core components required
throughout the treatment process.
Psychiatry
The relative necessity of these com-
ponents is determined by the pa-
tient’s clinical condition.
Program milieu. The program
environment will affect retention of
patients over time ( 1 0). For the more
disturbed chronic psychiatric pa-
tient, highly structured but low-in-
tensity programs are necessary (35).
Impulsecontroishould be promoted
in the hope that social norms will be
internalized, allowing patients to ad-
just more adequately to the com-
munity. The literature on expressed
emotion (36)suggests that treatment
settings should seek to reduce inter-

personal stimulation. Some authors
advocate psychoeducational pro-
gramming (21,37). Available pro-
gram descriptions are consistent
with these principles for structuring
the treatment milieu (17,20,21).
Case management. In the treat-
ment of the dually diagnosed pa-
tient, a primary ongoing therapeutic
relationship is necessary. For the
severely disturbed patient, this rela-
tionship may be with a case manager.
Assertive case management models,
which were developed to respond to
the needs of difficult-to-treat psychi-
attic patients (38), have been recom-
mended for the dually diagnosed
patient (39).
In these models, case managers
perform assertive outreach, link pa-
tients with direct services, monitor
patients’ progress through a variety
of milieus, educate patients about
psychiatric and substance abuse dis-
orders, reiterate treatment recom-
mendations, and coordinate treat-
ment planning across programs. In
developing individualized treatment
plans, the case manager clarifies the
patient’s expectations and explains
what the patient can expect from the
case manager. Research is under way

to determine if assertive case man-
agement is effective for the dually
diagnosed population (39).
Group therapy. Alongwith other
clinicians (17,20,21), we consider
group therapy the foundation of ac-
tive treatment interventions for the
dually diagnosed patient. Even
severely disturbed patients can
benefit from group therapy (40).
Group participants should be
screened for verbal, social, and cog-
nitive skill levels. These assessments
can be used to create groups com-
posed ofpatients with similar levels
of functioning.
In groups for lower-functioning
patients, the pace should be slow.
Less confrontation and more active
group leaders are appropriate. Solic-
itation of thoughts and feelings may
be minimal; instead the group may
focus on symptom reduction and be-
havioral change. In higher function-
inggroups or over a longer period of
time in lower-functioning groups,
more peer interaction is promoted.

The development and monitoring of
individual treatment contracts by the
group is encouraged.
A psychoeducational approach
has been proposed for the treatment
of dually diagnosed patients within
groups (2 1 ,4 1). Providing informa-
iion while developing a supportive
peer group facilitates movement
through treatment phases. Under-
standing and acceptance of both the
psychiatric illness and the substance
dependence, obtaining an awareness
ofthe patients’ prodromes and active
symptoms, and promoting medica-
tion compliance are ongoing tasks in
group therapy of dually diagnosed
patients.
Psychopharmacology. Dually di-
agnosed patients with poorly con-
trolled psychiatric symptoms or dis-
tressing drug side effects such as
akathisia are more likely to resume
substance abuse. A dually diagnosed
patient’s psychiatric disorder will
often respond to medication, al-
though increased attention to the
patient’s medication compliance is
necessary. The use of long-acting
depot neuroleptics may be helpful.
However, the use of minor tran-
quilizers with addiction-prone pa-

tients is controversial (42). Clini-
cians should be aware ofthe possible
abuse ofanticholinergic agents, such
as benztropine and trihexyphenidyl
(43), and should carefully review
their use.
The interaction between pre-
scribed drugs and abused psychoac-
tive substances is another area that
requires monitoring. Clinicians must
consider metabolic interactions,
such as enzyme induction, and phys-
iologic interactions, such as neuro-
transmitter dysregulation, when pre-
scribing medication to addicted pa-
tients. These poorly understood
interactions are less problematic as
patients reduce and eliminate their
substance abuse.
The use of disulfiram in patients
with psychotic disorders is parti-
cularly controversial. Despite �he
reported psychotogenic effects me-
diated by dopamine beta-hydroxy-
lase (44,45), our experience suggests
that disulfiram is less of a risk to pa-
tients’ psychiatric status than alcohol
if they are psychiatrically stabilized
and placed on appropriate main-
tenance pharmacotherapy before

disulfiram is administered. Dually
diagnosed patients have been found
to be at least as compliant with disul-
firam as primary alcoholics (17,46).
Valid consent (47) is necessary be-
fore prescription of any medication,
particularly disulfiram.
For opiate-dependent dually di-
agnosed individuals, methadone
maintenance treatment may be use-
ful. Methadone will not interfere
with the action ofantipsychotics and
may even enhance their effective-
ness (48). The role of the narcotic
antagonist naltrexone with dually
diagnosed patients has not been ade-
quately studied. Desipramine has
been reported to reduce craving and
relapse in cocaine-dependent pa-
tients (49) and could also have a role
in the management of coexisting af-
fective disturbances.
Detoxification. Detoxification
may be a necessary, but never suffi-
cient, component in the treatment of
substance dependence. While am-
bulatory detoxification is possible,
many dually diagnosed patients may
require hospitalization for behavior-
al control or medical management.
Such patients have historically been
poorly tolerated in nonhospital com-
munity detoxification centers and

frequently must be treated on psy-
chiatric wads (22).
Because intoxicated patients are
especially impulsive, evaluation of
personal and community safety is
paramount. The site for detoxifica-
tion of the dually diagnosed patient
10 1029
will be determined partly by an as-
sessment of the potential for be-
havioral disturbance and of staff
capacities for managing disturbance.
When hospitalization is deemed
necessary, the patient should be in-
formed of all factors contributing to
that recommendation. The patient
should also be told that detoxifica-
tion without rehabilitation is of no
long-term benefit. The expectation
that the patient will use the hospital
stay to initiate rehabilitative treat-
ment should be made clear.
Whether patients with preexist-
ing psychotic disorders are more
prone than primary substance
abusers to severe withdrawal psy-

choses is unclear. The differential
diagnosis of psychotic symptoms in
the setting of acute withdrawal is
both difficult and essential. Objec-
tive data such as vital signs, evidence
of tremor and hyperreflexia, pupil
size, and the results of Breathalyzer
tests and urine or serum drug screens
are necessary for differential diag-
nosis and treatment. The psychotic
symptoms of acute withdrawal may
require management with antipsy-
chotic agents, but these symptoms
usually remit within two weeks (50).
The need for maintenance antipsy-
chotics should be reassessed after
withdrawal features have cleared.
Toxicologic screening. Regard-
less of a substance abusers’ underly-
ing psychiatric status, denial and
deceptive behaviors are part of the
disease process even in the most im-
paired patients. The role ofthese be-
haviors has been highlighted by Al-
terman and associates’ finding (51)
that more than half of alcoholic
schizophrenic patients continued to
drink while hospitalized and by Hel-
zer and Pryzbeck’s report (25) that
although dually disordered alcoholic
patients are morelikely to seek treat-
ment than primary alcoholics, they

are no more likely to have discussed
their drinking with a treating phy-
sician.
Programs for dually diagnosed
patients should use random Breath-
alyzer and urine drug screens to
detect unacknowledged relapse.
The belief that patients’ capacity for
deception is diminished by psychiat-
ric illness is frequently challenged by
the positive results ofroutine chemi-
cal testing. Such testing reinforces
the abstinence orientation of the
treatment milieu, provides patients
with an external reason to remain
abstinent during the period before
their internalization of this goal, and
offers patients who are successfully
abstinent an opportunity to ex-
perience growing credibility and
self-confidence within the treatment
program.
Family involvement. F a m i 1 y
members are often the first to recog-
nize the destructive consequences of
substance abuse in their loved ones’
psychiatric course. They should be
informed ofthe vulnerability of their
family member’s illness to what may
appear to be harmless drug use.

They will need help in finding a deli-
cate balance between offering sup-
port to their family member and ac-
ting in ways that enable him to con-
tinue destructive drug use.
Family involvement in develop-
ing treatment contracts and monitor-
ing compliance can increase patient
motivation. Including family psy-
cheducation (52) in the treatment
program may reduce not only
episodes ofpatient relapse but also
the family’s perceived burden (37).
The National Alliance for the Men-
tally Ill (NAMI), a family support
network, has been active in seeking
services for dually diagnosed pa-
tients. Al-Anon may help families
understand and respond to alcohol
abuse problems. These support
groups can help families maintain a
caring relationship with their dually
diagnosed member through all
phases of treatment.
Self-help groups. The use of self-
help groups in the treatment of the

dually diagnosed patient must be
evaluated on a case-by-case basis.
Frequent, accessible, and inexpen-
sive meetings, a positively focused
and structured 1 2-step recovery pro-
gram, and the possibility of meaning-
ful personal sponsorship make this
kind of intervention an important
component of many treatment plans
for dually diagnosed patients. How-
ever, a patient’s ability to internalize
the programs of Alcoholics Anony-
mous or Narcotics Anonymous ap-
propriately or to fit into a specific
meeting should not be assumed.
While AA principles are not anti-
psychiatry or antimedication, those
sentiments may exist within in-
dividual members or groups and
should be discussed before the
patient attends AA events. Case
managers may attend meetings with
their clients and process the informa-
tion with them afterward. Some
dually diagnosed patients may at
times be too disruptive for these
meetings and should be discouraged
from attending until they have be-
come more stable.
The emergence of self-help

groups with specific dual-diagnosis
orientations has been a welcome al-
ternative for more severely impaired
patients. While using AA principles,
the dually diagnosed members em-
pathically support mental health
treatment and tend to be more
tolerant of deviant behaviors. Many
of the successfully recovering dually
diagnosed patients treated by the
authors have used self-help groups as
part oftheir treatment.
Conclusions
Severe psychiatric disorders impair
the ffectiveness of traditional sub-
stance abuse treatments. Nonethe-
less, treatment interventions for
dually diagnosed patients ranging
from modest modifications (2 1) to
complex new programs (1 7,20) may
reduce this effect and produce
improvement in some previously
refractory patients. The integration
of substance abuse treatment into
mental health settings augments the
community support programming
that currently exists for the severely
and chronically mentally ill. Cli-
nicians must define, develop, imple-
ment, and scientifically evaluate
programs for the dually diagnosed
patient.
References

I . Safer D: Substance abuse by young adult
chronic patients. Hospital and Com-
munity Psychiatry 38:5 1 1-5 14, 1987
2. Goldfinger SM, HopkinjT, SurberRW:
Treatment resisters or system resisters?
Toward a better service system for acute
cane recidivists. New Directions forMen-
Psychiatry
talHealth Services, no 21:17-27, 1984
3. Drake RE, Osher FC, Wallach MA: Al-
cohol use and abuse in schizophrenia a
prospective community study.Journal of
Nervous and Mental Disease 177:408-
414, 1989
4. Koegol P, Burnam MA: Alcoholism
among homeless adults in the inner city
ofLos Angeles. Archives ofGeneral Psy-
chiatry 45:1011-1018, 1988
5. Benda BB, Dattalo P: Homelessness:
consequence of a crisis or a long-term
process? Hospital and Community Psy-

chiatry 39:884-886, 1988
6. Richardson MA, Craig 17, Haugland G:
Treatment patterns of young chronic
schizophrenics in the era of deinstitu-
tionalization. Psychiatric Quarterly 57:
243-249, 1985
7. Caton C: The new chronic patient and
the system of community care. Hospital
and Community Psychiatry 32:475-478,
1981
8. McCarrickAK, Manderscheid RW, Ber-
tolucci DE: Correlates of acting-out be-
haviors among young adult chronic
patients. Hospital and Community Psy-
chiatry 36:848-853, 1985
9. LaPorte DJ, McLellan AT, O’Brien CP,
et al: Treatment response in psychiatni-
cally impaired drug abusers. Compre-
hensive Psychiatry 22:41 1-419, 1981
10. McLellan AT: Psychiatric severity as a
predictor of outcome from substance
abuse treatments, in Psychopathology
and Addictive Disorders. Edited by

Meyer RE. New York, Guilford, 1986
1 1. Test MA, Knoedler WH, Allness DJ, et
al: Characteristics of young adults with
schizophrenic disorders treated in the
community. Hospital and Community
Psychiatry 36:853-858, 1985
12. Bachrach LL: Young adult chronic pa-
tients: an analytical review of the litera-
tune. Hospital and Community Psychia-
try 33:189-197, 1982
13. SheetsJ, PrevostJA, ReihmanJ: Young
adult chronic patients: three hypothe-
sized subgroups. Hospitaland Commun-
ity Psychiatry 33:197-203, 1982
14. SchuckitMA:Theciicalimplicationsof
primary diagnostic groups among al-
coholics. Archives ofGeneral Psychiatry
42:1043-1049, 1985
15. Rounsavile BJ, Dolinsky ZS, BaborTF,
et al: Psychopathology as a predictor of
treatment outcome in alcoholics. Ar-
chives of General Psychiatry 44:505-
513, 1987
16. Woody GE, McLellan AT, Luborsky L,

et al: Severity ofpsychiatric symptoms as
a predictor of benefits from psycho-
therapy: the Veterans Administration-
Penn study. AmericanJournal of Psychi-
atry 141:1172-1177, 1984
17. Kofoed L, KaniaJ, Walsh T, et al: Out-
patient treatment of patients with sub-
stance abuse and co-existing psychiatric
disorders. American Journal of Psychia-
try 143:867-872, 1986
18. GalanterM, CastanedaR, FermanJ: Sub-
stance abuse among general psychiatric
patients: place ofpresentation, diagnosis,
and treatment. American Journal of
Drug and Alcohol Abuse 14:211-235,
1988
19. BloomJD, BradfordJM, Kofoed L: An
overview of psychiatric treatment ap-
proaches to three offender groups. Hos-
pital and Community Psychiatry 39:
151-158, 1988
20. Ridgely MS. Osher FC, Talbott JA:
Chronic Mentally IllYoung Adults With

Substance Abuse Problems: Treatment
and Training Issues. Rockville, Md, Al-
cohol, Drug Abuse, and Mental Health
Administration, 1987
2 1. Hellerstein DJ, Meehan B: Outpatient
group therapy for schizophrenic sub-
stance abusers. Amenicanjournal of Psy-
chiarry 144:1337-1339, 1987
22. Pinsker H: Addicted patients in hospital
psychiatric units. Psychiatric Annals 13:
619-623, 1983
23. Kofoed LL, KeysA: Usinggroup therapy
to persuade dual-diagnosis patients to
seek treatment. Hospital and Commun-
ity Psychiatry 39:1209-121 1, 1988
24. BakerSL, LoreiT, McKnightJ, et al:The
Veterans Administration comparison
study: alcoholism and drug abuse-corn-
bined and conventional treatment set-
tings. Alcoholism: Clinical and Expeni-
rnentalResearch 1:285-291, 1977
25. Helzer JE, Pryzbeck TR: The co-occur-
rence of alcoholism with other psychiat-
nc disorders in the general population

and its impact on treatment. Journal of
Studieson Alcohol49:219-224, 1988
26. Gerstley L, McClellan AT, Alterman A!,
et al: Ability to form an alliance with the
therapist: a possible marker of prognosis
for patients with antisocial personality
disorder. Americanjournalof Psychiatry
146: 508-512, 1989
27. Gelberg L, Linn LS, Leake BD: Mental
health,alcoholand druguse, and criminal
history among homeless adults. Amen-
canJournal ofPsychiatry 145: 19 1-196,
1988
28. Atkinson RM: Persuading alcoholic pa-
tients to seek treatment. Comprehensive
Therapy 11:16-24, 1985
29. Stark MJ, Kane BJ: General and specific
psychotherapy role induction with
substance-abusing clients. International
Journal of the Addictions 20:1135-
1141, 1985
30. Clank WD: Alcoholism: blocks to diag-
nosis and treatment. Amenicanjournal of
Medicine 71:275-286, 1981

3 1. Rawson RA, Mann AJ,Tennant FS, et a!:
Efficacy ofpsychotherapeutic counseling
during 2 1-day ambulatory heroin detox-
ification, in Problems of Drug Depend-
ence. ResearchMonograph43. Edited by
Harris LS. Rockville, Md, National In-
stitute on Drug Abuse, 1983
32. Dolan LP: An intake group in the a!-
coholism outpatient clinic. Journal of
Studies on Alcohol 36:996-999, 1975
33. Cronkite R, Moos RJ: The determinants
ofposttreatment functioning of alcoholic
patients: a conceptual framework. Jour-
nalofConsultingandCliicalPsychology
48:305-316, 1980
34. Marlatt GA, Gordon JR: Relapse Pre-
vention. New York, Guilford, 1985
35. Finney JW, Moos RH: Environmental
assessment and evaluation research: ex-
amples from mental health and substance
abuse programs. Evaluation and Program
Planning 7:151-167, 1984

36. LeffJ, Vaughn C: Expressed Emotion in
Families. New York, Guilford, 1985
37. Drake RE, Oshen FC: Using family
psychoeducation when there is nofamily.
Hospital and Community Psychiatry
38:274-277, 1987
38. Stein LI, Diamond RJ: A program for
difficult-to-treat patients. New Direc-
tions for Mental Health Services, no
26:26-39, 1985
39. Teague G, Mercen-McFadden C, Drake
RE: Dual diagnosis and continuity of
care: New Hampshire’s integrated initia-
tives for dual-diagnosis patients. Tie
Lines 6(1):1-3, 1989
40. O’Brien CP: Group psychotherapy with
schizophrenic and affective disorders, in
Comprehensive Group Therapy, 2nd ed.
Edited by Kaplan HI, Sadock BJ. Bal-
timore, Williams & Wilkins, 1983
41. Hendrickson EL: Taking a look at
psychoeducation and a group for dual-
disorder patients. Tie Lines 6(1):3-5,
1989

42. Cinaulo DA, Sands BF, Shader RI: Clii-
cal review ofliability for benzodiazepine
abuse among alcoholics. American jour-
nal ofPsychiatny 145:1501-1506, 1988
43. DiSalver SC: Antimuscaninic agents as
substances of abuse: a review. journal of
Clinical Psychopharmacology 8:14-22,
1988
44. EwingjA, MealIer RA, Rouse BA, eta!:
Lowlevels ofdopamine beta-hydoxylase
and psychosis. Amenicanjournal of Psy-
chiarny 134:927-928, 1977
45. Major LF, Lerner P. BallengerJC, et a!:
Dopamine beta-hydroxylase in the cere-
brospinal fluid: relationship to disul-
finam-induced psychosis. Biological Psy-
chiatry 14:337-344, 1979
46. Kofoed LL: Chemical monitoring of di-
sulfiram compliance: a study of alcoholic
outpatients. Alcoholism: Clinical and Ex-
penimentalResearch 11:481-485, 1987

47. Culver CM, Gent B: Valid consent and
competence, in Philosophy in Medicine.
Edited by Culver CM, Gent B. New
York, Oxford University Press, 1982
48. BnizerDA, Hartman N, Sweeneyj, eta!:
Effect ofmethadone plus neuroleptics on
treatment-resistant chronic paranoid
schizophneia. Amenicanjournal of Psy-
chiatry 142:1106-1107, 1985
49. Gawin FH, Kleben HD: Cocaine abuse
treatment: open pilot trial with desip-
ramine and lithium carbonate. Archives
ofGeneral Psychiatry42:903-910, 1984
50. Schuckit MA: Drug and Alcohol Abuse:
A Clinical Guide to Diagnosis and Treat-
ment, 2nd ed. New York, Plenum, 1984
5 1. Alterman A!, Erdlen DL, LaPorte Dj, et
a!: Effects ofillicit drug use in an inpatient
psychiatric population. Addictive Be-
haviors 7:231-242, 1982
52. Bernheim KF, Lehman AF: Working
With Families of the Mentally IlL New
York, Norton, 1985
Running head: MINI-INTERVENTION 1: CLASSROOM
CULTURE CHANGEMINI-INTERVENTION 1: CLASSROOM

CULTURE CHANGE
Classroom Culture Change
Carzetta Allen
Capella University
1. Describe your current classroom management style and how
it affects the management of diverse learners.
My current classroom management style is more of a conductor.

I love to be the one who gives the instructions, and make sure
that all students understand them. I emphasize how important
classroom rules and expectations were at the beginning of the
year. During the year, I made sure that I kept those same
classroom rules and expectations. I repeated the same thing over
and over again and it got a little tiresome, but it is worth it in
the end. I try to make it a habit to talk about what was done
correctly and what was done incorrectly so the students know
what they done wrong so that they can fix the problem.
According to Schindler (2010), out of this structure, the
objectives of a prolific learning environment, respect,
accountability, and positive relationships are builder. For
example, let's say we are trying to converge into groups. Before
we transition into groups, I explain to them that we will be
moving into groups and then continue to give them the
expectations. After we transition, I explain with the students the
challenges and the outcome of the transition. By doing this,
students will see what they done correctly and what they did
incorrectly hopefully with a chance to fix the problem. With
this pathway I would like to think that losing only to win is a
tremendous way to describe this pathway.
2. Describe a classroom management practice to change and
describe the desired effects of the change in detail.
A classroom management practice I would like to change would
be maximizing the use of my teaching time and becoming more
of an authoritative type of teacher. A lot of classroom
management concerns can be traced back to how the lesson is
formulated. Is there any free time? Can students move from one
assignment to the next? When they get to the assignment, are
they seriously engaged in learning or are they spending most
time entertaining? These are the kinds of questions that I think
about as I try to modify this change. In doing this, I hope to
accomplish a structured classroom. More often than not, when
there's more free time the more teaching time, that's when

problems start arising. There will be no student that can focus
on the real work; instead they'll be focus on what the prankster
is doing, given the teacher more behaviors to correct.
3. Propose an immediate implementation plan that targets a
specific change in classroom management
For beginner, the best thing to do would be to plan ahead with
my lessons. Because we are on block scheduling, it would be
best to plan for at least three weeks in advance so that I may
have a hold on what I am going to be doing in the classroom. I
need to know what tangibles are needed for each student and if
possible I need to copy them just in case I run out or someone
forgets something. When the students arrive in the classroom, I
would begin with an anticipatory set. The students will be ready
for the lesson ahead. Once the lesson has begun, I will start
explaining what to do and how I would like it to be done. The
assignments will be timed and after the bell rings, it will be
time to switch to the next assignment. We will do this until it is
time to wrap up. The wrap up will be an exit ticket based on
what they have learned.
4. Develop a script to introduce and approach this management
change with students that includes specific, age-appropriate
details.
When I arrived in the classroom, I would say:
“Good morning class. I hope you are ready for a good weekend.
Today I wanted to go over a couple of things and introduce
some new things that will be done in the classroom. Now that
you are in middle school, I assume that you will know how to
behave. I have been doing some thinking over the weekend, and
I know that you are old enough to know better, but you still
have to obey and follow the rules. I want you to understand that
as a class it is okay if we have conversations, laughed, joke, but
we also need to understand that when it is time for work, I mean
business. In the meantime, I am going to go over my classroom
rules and expectations until I feel that you are responsible

enough to conduct yourselves without me being so much of a
dictator. Hopefully you know that this is coming from a very
good place and I have great plans."
5. Describe a way to measure changes in the classroom climate
based on specific changes in instructor behaviors.
A way to measure changes in the classroom climate would be
for students to do surveys. Teachers should give out these
surveys to their students at the end of the year. Student surveys
give teachers the concepts of their teaching through the eyes of
their students. It's best that the survey is completed
unidentified, that way the teacher doesn't get upset at a certain
student. Honesty is the best policy, is it better to learn from
them or the ones who see you every day? When feedback that
students provide about their teacher is useful in helping teachers
improve and fine-tune their teaching. It will benefit teachers in
allowing them to hear their students concerns while there still
time to correct those concerns. The surveys benefit both the
student and the teacher. The teacher asks particular questions
and hopefully be honest with themselves and the students. Most
times the questions are geared towards what the teacher may
think they are doing wrong in the classroom. If these questions
are put on a survey, students can answer them so that the
teacher may give back.
**************************
6. Results and Reflection
[You will not complete this part in Unit 4; in Unit 10, you will
submit this as part of your Classroom Management Portfolio.
After you collect data for a couple of weeks on your change,
return to your document and report your results and your
reflection on the change here for submission later.]
Reference
Shindler, J. (2010). Transformative classroom management:

Positive strategies to engage all students and promote a
psychology of success. San Francisco, CA: Jossey-Bass.
Peer-Feedback Form
Ask a fellow peer to provide feedback on what you have
written. They should check off the box next to each question,
and write a brief comment that will improve your work.
Peer reviewer: Danielle Preciado Date:
5/2/2018
Trait on which to provide feedback
Yes
No
Comments
Describes current classroom management practices and how
they affect the management of diverse learners.
X
Identifies a classroom management practice to change and
describes the desired effects of the change in detail.
X
Describes a way to measure changes in the classroom climate
based on specific changes in instructor behaviors.
X
Is the classroom culture change well organized?
X

Is critical thinking evident?
X
Is the writing clear and concise?
X
Do word usage errors occur?
X
Do grammatical errors occur?
X
Do mechanical errors occur? (Punctuation, capitalization, et
cetera).
X
Is APA 6th edition used correctly?
X

Rubric Instructions: Self-Assessment of Competencies
The idea behind rubrics is to assist you in critically analyzing
your work and ability to meet competencies that are aligned to
criteria on the rubrics. With self-assessment and reflection of
the criteria on the rubric prior to submission, you will have a
solid idea of your competency and quality of work. Regular use
of self-assessment as a way to reflect will improve your writing
and target assignments toward your instructor’s expectations.
You will use the same rubric that the instructor uses for each
assignment. You will grade your own assignment using the
rubric, as will your instructor. After submission, your instructor
will compare the two rubrics. If they match, you will earn extra
points. However, in the end, your instructor’s assessment will
be the one that counts.
Process for Self-Assessment
1. Think critically about your work before filling out the rubric.
So, be honest in your appraisal of your work.
2. Use this assignment template and rubric. Upload to the
appropriate assignment area.
3. Assess your assignment according to the rubric. Include
comments that share how your assignment meets the level you
chose along with evidence from your assignment. Boldface
words, phrases, or parts in your assignment that you feel
support your level choice and comments.
4. Refer to the boldface when you type your comments in the
comments column. This becomes evidence of how you have
demonstrated your competency related to the chosen level.
5. Your instructor will assess using the same rubric; if the
rubrics match, you will earn extra points.
Criteria
Non-performance

Basic
Proficient
Distinguished
Comments
Describe current classroom management practices and how they
impact management of diverse learners.
20%
Does not describe classroom management practices or address
how these practices impact the management of diverse learners.
Does not describe classroom management practices or address
how these practices impact the management of diverse learners.
Describes current classroom management practices and
addresses how they impact the management of diverse learners.
Creates a detailed description of current classroom management
practices, and includes multiple examples of most common
practices and how these practices impact the management of
diverse learners.
I have described my classroom styled in full detail.
Describe the effects desired as a result of changing (increasing,
decreasing, or eliminating) a specific classroom management
practice.
20%
Does not describe the effects desired as a result of changing
(increasing, decreasing, or eliminating) a specific classroom
management practice.
Does not describe the effects desired as a result of changing
(increasing, decreasing, or eliminating) a specific classroom
management practice.
Describes the effects desired as a result of changing (increasing,
decreasing, or eliminating) a specific classroom management
practice.
Identifies a classroom management practice to change and
describes the desired effects of the change in detail. Provides a
strong rationale for the selection and supports the rationale with
examples from other practitioners.
The goal here is to identify the change that you would like to

see in yourself and the students you teach. That problem is
identified, but lacks references.
Describe a way to measure changes in the classroom climate
that is based on specific changes in instructor behaviors.
20%
Does not describe a way to measure changes in the classroom
climate that is based on specific changes in instructor
behaviors.
Describes a classroom climate change, but does not connect it to
specific changes in instructor behaviors.
Describes a way to measure changes in the classroom climate
that is based on specific changes in instructor behaviors.
Describes in detail a way to measure change, demonstrating the
appropriateness of the measurement based on the changes they
make in their own behaviors.
Surveys help teacher understanding the perspectives of their
students. We too, often forget that sometimes a child can be the
best wake up call.
Develop a script to introduce and approach this management
change with students.
20%
Does not develop a script to introduce and approach this
management change with students.
Develops a script that lacks sufficient detail in the description
of how they would introduce and approach this management
change with their students.
Develops a short script in which a teacher describes how to
introduce and approach the change with students.
Develops a script to introduce and approach this management
change with students that includes specific, age-appropriate
details.
Provided within the assignment, I have included a way that I
would address the class if the said action plan were to take
place.
Propose an immediate implementation plan that targets a
specific change in classroom management behaviors.

20%
Does not propose an immediate implementation plan or target a
Proposes an immediate implementation plan but fails to include
details about how they will make the change to their own
management behavior.
Proposes an immediate implementation plan and targets a
Proposes an immediate implementation plan and demonstrates a
thoughtful rationale for the choice while providing a detailed
description of how they will make the change in their own
management behavior.
I mention that students will be timed with every assignment. If
this is done with fidelity, students will know just what is to be
expected of them after every time the timer stops.

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Hospital and Community Psychiatry October 1989 Vol. 40 No. 10 .docx