CLINICAL HANDBOOK OF SCHIZOPHRENIA

44. Management of Co-Occurring Substance Use Disorders 463is also tempting for friends and relatives to blame substance users with serious mentaldisorders for their own symptoms. These reactions substantially increase the risk of subsequentpsychotic relapse. In fact, this indirect influence can sometimes be stronger thandirect effects of the drug. Exclusion and rejection are seen in a number of contexts, unfortunately,including health services and assisted accommodation. Effects of such exclusioncan be catastrophic.There are at least two implications for treatment. First, interventions assisting familiesand friends to cope with the person’s co-occurring psychosis and SUD may be veryimportant. Second, we should ensure that our reactions to these people do not worsentheir prognosis or lead to their permanent exclusion. Although there are good reasons toban substance use within specific contexts (e.g., on treatment or accommodation sites, orbefore sessions), avenues for support and treatment of those who do use must remainopen. Any consequences should be proportional, temporary, demonstrably fair (e.g., abbreviationand rescheduling of the session), and protective of the health and welfare of allparties. It is no more appropriate to exclude lapsing substance users from service than toexclude people with symptomatic exacerbation from appropriate service responses.The large impact that typically follows relatively low consumption of recreationaldrugs means that the majority of people with serious mental disorder and an SUD whoare seen in most mental health services do not show high levels of physical dependence orneed assisted withdrawal. This is not to say that attention to physical risk is unimportant:Both the psychosis and the substance use increase the risk of physical exposure, impairedself-care, injury, and infection (including infection with HIV). Self-harm, suicide, and eithercommitting assault or being the victim of it are more likely in people with an SUDthan in those without an SUD, and assessment of these risks is essential. Given the heightenedrisk of serious physical disorder in this population, and the risk of misdiagnosis orinadequate treatment, mental health and SUD services have an obligation to provide relevantconsultation and training to ensure that general medical staff are able to meet thesignificant challenges this population may pose. Services are also needed for people withboth a severe mental disorder and severe substance dependence, who often need a highlevel of ongoing treatment and support, and input from a range of specialist services.Often There Is Little Else in the User’s LifeSubstance use in people with psychosis is usually in the context of a very impoverishedexistence, with drug users constituting their primary or only friends, and with few alternativerecreational activities. These individuals rarely use substances to address psychoticsymptoms, but they often cite relief of dysphoria or boredom as key reasons for consumption.Corollaries are that motivation enhancement and relief of dysphoria may beimportant components of successful treatment. Because dysphoria lowers self-efficacy,strategies that boost confidence and address responses to perceived failures may often berequired. Interventions need to provide more social advantages and opportunities formood enhancement than they take away.This Group Usually Has Complex, Intertwined IssuesThe term dual diagnosis comes nowhere near an accurate description of the complexity ofproblems typically seen in this population. Most people with psychosis and co-occurringSUD use more than one substance, and many have additional mental health problems(e.g., depression, social anxiety, and personality disorders). As already noted, often they