CLINICAL HANDBOOK OF SCHIZOPHRENIA

44. Management of Co-Occurring Substance Use Disorders 467Up to now, there has been little success in a priori identification of consumers whowill benefit from brief comorbidity interventions. Those with less severe or less chronicproblems, for example, do not necessarily show better outcomes. This observation, togetherwith cost considerations, suggests that a staged model of intervention may be indicated,in which all affected consumers receive a brief intervention, with some repetition inindividuals with fragile motivation. Motivated consumers who have difficulty maintainingan attempt may need additional support and targeted skills training, or adjunctivepharmacotherapy. A small group that is at acute physical and psychiatric risk and is unableto respond to skills training may need more intensive environmental support (e.g.,supervised living environments). Such a staged approach to treatment delivery wouldneed to ensure that consumers not see stage progression as a reflection of their own failure(perhaps by drawing an analogy to particular medications being more effective withsome people than others).GUIDELINES FOR PSYCHOLOGICAL TREATMENTWhere does this leave us as practitioners? Given the current state of the evidence, any recommendationsmust be tentative. When the epidemiological and treatment outcome researchare considered, some specific guidance is given. Table 44.1 summarizes the implicationsfor treatment relative to the issues already discussed in preceding sections. Butwhat components of psychological intervention should be considered?Development of RapportIt is critical that clients trust that the information they divulge will not result in negativeoutcomes (exclusion from service, legal consequences, or disapproval); otherwise, theywill withhold information about substance use (and other potentially sensitive issues).One the one hand, at least “denial” of problems may also be more accurately describedas nondisclosure. On the other hand, provided that rapport and trust are well established,reports of consumption can be as accurate as assays (or more so, if a report extendsbeyond the detection period of the assay). Trust is established by the therapist demonstratingempathy and positive regard in response to other personal information, and byproviding specific reassurance about lack of consequences for disclosure. General conversationsabout the person’s interests, usual activities, and goals are especially useful in latermotivational interviewing.Brief Intervention or AdviceIf there is insufficient opportunity for anything more, people with comorbidity should beprovided nonjudgmental feedback on outcomes of screening and assessment. Brief advicefrom an expert may be persuasive in some cases, particularly if the person is already concernedabout the issue. However, highly confrontational interactions should be avoidedin this population, because of their potentially detrimental symptomatic impact. Furthermore,some people are likely to react defensively to direct suggestions about either theirsubstance use or concurrent mental disorder. Motivational interviewing (Miller &Rollnick, 2002) minimizes defensive reactions and often elicits motivation for change,even when the person was not initially contemplating it. Adjustments for people with seriousmental disorder may include splitting the process into several short sessions, revisingthe process on each occasion, and including more summaries than usual. We havefound that the approach can even be used during a psychotic episode, as long as clients