DISCUSSION AND CONCLUSIONS

The profoundly negative impact of substance abuse on the course of severe psychiatric disorders has become a major focus of attention, and a concerted effort over the past decade to improve the outcomes of these clients has already begun to pay off. Longitudinal research on the course of dual disorders in clients who received treatment from the traditional parallel service system indicated a very slow rate of recovery, with usually less than 5 percent becoming abstinent each year. Growing discontentment with the parallel treatment approach rapidly led to the development of a different, broad-based model that seeks to improve outcomes by integrating mental health and substance abuse treatments. Preliminary studies employing a range of different integrated treatment models have yielded promising results that suggest better outcomes than those traditionally produced by the parallel service system. Despite the hopeful findings of these studies, many questions remain unanswered about integrated treatment. One thorny issue has been the difficulty of comparing parallel and integrated treatment programs. Most of the evidence supporting integrated treatment programs is derived from either noncontrolled studies that followed the progress of a group of clients who received integrated treatment, or controlled studies comparing the efficacy of different models of integrated treatment. Direct comparisons of integrated and parallel treatment approaches have proved impossible to study because of treatment drift; as soon as clinicians providing parallel treatment become aware that mental health and substance abuse inter-ventions can be integrated, they begin to do so, thereby compromising their fidelity to the parallel services model. For this reason, it is not clear whether controlled research will ever be conducted that definitively demonstrates the superiority of integrated treatments over parallel ones, although integrated treatment is rapidly becoming the status quo. Another question concerns the effects of group interventions for dually diagnosed clients. A number of different group interventions have been described, with foci ranging from persuasion (Noordsy and Fox 1991), problemsolving (Carey et al. 1990), and social skills training (Nikkel 1994) to broad-base supportive/education/skills building (Hellerstein and

Meehan 1987). Although group treatment is a common ingredient in many integrated programs, no consensus exists as to the optimal format, content, or goals of these groups. Research is needed to evaluate the benefits of different approaches to group treatment for dually diagnosed clients and to explore whether certain clients are likely to gain more from a particular group format. A final question concerns the comparative efficacy of different integrated treatment models. Thus far, the evidence suggests that different approaches to providing integrated treatment for dually diagnosed clients result in similar rates of improvement (Jerrell and Ridgeley 1995; Drake et al., under review). These results, if supported by other ongoing research, could have important policy implications. If different treatment programs result in comparable benefits, then the adoption and dissemination of integrated treatments should perhaps be determined by ease of implementation and cost. Of related importance, the determination of which clients benefit from which programs (or program components) could also have implications for tailoring treatment to best suit the needs of individual clients. There have been tremendous strides in the past 10 years in the development of effective interventions for persons with dual disorders. The results of research conducted thus far provide grounds for cautious optimism. At the same time, there is still much work to be done to help clients recover from the double handicap of mental illness and substance use disorder. The significant advances made in the past decade by professionals, working in collaboration with clients and their families, auger well for improving the long-term outlook of dually diagnosed persons. REFERENCES

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