is an integrated approach to treatment of patients
with drug use disorders and comorbid psychiatric
disorders. The DDRC model, which integrates
individual and group addiction counseling
approaches with psychiatric interventions,
attempts to balance the focus of treatment so that
both the patient’s addiction and psychiatric issues
are addressed.
The DDRC model is based on the assumption that
there are several treatment phases that patients
may go through. These phases are rough
guidelines delineating some typical issues patients
deal with and include:
Phase 1—Engagement and Stabilization. In
this phase, patients are persuaded, motivated, or
involuntarily committed to treatment. The main
goal of this phase is to help stabilize the acute
symptoms of the psychiatric illness and/or the drug
use disorder. Another important goal is to
motivate patients to continue in treatment once the
acute crisis is stabilized or the involuntary
commitment expires. Dealing with ambivalence
regarding recovery, working through denial of
either or both illnesses, and becoming motivated
for continued care are other important goals
during this phase.
This phase usually takes several weeks, but for
some patients it takes longer to become engaged
in recovery and to stabilize from acute effects of
their dual disorders.
Phase 2—Early Recovery. This phase
involves learning to cope with desires to use
chemicals; avoiding or coping with people, places,
and things that represent high-risk addiction
relapse factors; learning to cope with psychiatric
symptoms; getting involved in support groups, such
as Alcoholics Anonymous (AA), Narcotics
Anonymous (NA), Cocaine Anonymous (CA),
Rational Recovery (RR), Dual Recovery
Anonymous, or mental health support groups;
getting the family involved (if indicated); beginning
to build structure into life; and identifying problems
to work on in recovery.
This phase roughly involves the first 3 months
following stabilization. However, some patients
take much longer in this phase because they do
not comply with treatment, continue to abuse
drugs, experience exacerbations of psychiatric
symptomology, or experience serious psychosocial
problems or crises.
Phase 3—Middle Recovery. In this phase,
patients continue working on issues from the
previous phase as needed. In addition, patients
learn to develop or improve coping skills to deal
with intrapersonal and interpersonal issues.
Examples of intrapersonal skills include coping
with negative affect (anger, depression, emptiness,
anxiety) and coping with maladaptive beliefs or
thinking. Interpersonal issues that may be
addressed during this phase include making
amends, improving communication or relationship
skills, and further developing social and recovery
support systems. This phase also focuses on
helping patients cope with persistent symptoms of
psychiatric illness; drug use lapses, relapses, or
setbacks; and crises related to the psychiatric
disorder. It also focuses on helping identify and
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manage relapse warning signs and high-risk
relapse factors related to either illness.
The middle recovery phase involves months 4
through 12, although some patients never get
much beyond early recovery even after a long
time in treatment. Patients who are treated for an
initial acute episode of psychiatric illness with
pharmacotherapy in addition to DDRC and who
do not have a recurrent or persistent mental illness
may be tapered off medications during this phase.
Patients are usually not tapered off medications
until they have several months or longer of
significant improvement in psychiatric
symptomology.
Phase 4—Late Recovery. This phase, also
referred to as the “maintenance phase” of
recovery, involves continued work on issues
addressed in the middle phase of recovery and
work on other clinical issues that emerge.
Important intrapersonal or interpersonal issues
may be explored in greater depth during this phase
for patients who have continued abstinence and
remained relatively free of major psychiatric
symptoms.
This phase continues beyond year 1. Many
patients with chronic or persistent forms of
psychiatric illness (e.g., schizophrenia, bipolar
disease, recurrent major depression), or severe
personality disorders such as borderline
personality disorder, often continue active
involvement in treatment. Treatment during this
phase may involve maintenance pharmacotherapy,
supportive DDRC counseling, or some specific
form of psychotherapy (e.g., interpersonal
psychotherapy). Involvement in support groups
continues during this phase of recovery as well.
1.2 Goals and Objectives of Approach
The goals of this counseling model are:
1. Achieving and maintaining abstinence from
alcohol or other drugs of abuse or, for
patients unable or unwilling to work toward
total abstinence, reducing the amount and
frequency of use and concomitant
biopsychosocial sequelae associated with
drug use disorders.
2. Stabilizing acute psychiatric symptoms.
3. Resolving or reducing problems and
improving physical, emotional, social, family,
interpersonal, occupational, academic,
spiritual, financial, and legal functioning.
4. Working toward positive lifestyle change.
5. Early intervention in the process of relapse to
either the addiction or the psychiatric
disorder.
1.3 Theoretical Rationale/Mechanism of
Action
The DDRC counseling approach involves a
broad range of interventions:
1. Motivating patients to seek detoxification or
inpatient treatment if symptoms warrant, and
sometimes facilitating an involuntary
commitment for psychiatric care.
2. Educating patients about psychiatric illness,
addictive illness, treatment, and the recovery
process.
3. Supporting patients’ efforts at recovery and
providing a sense of hope regarding positive
change.
4. Referring patients for other needed services
(case management, medical, social,
vocational, economic needs).
5. Helping patients increase self-awareness so
that information regarding dual disorders can
be personalized.
6. Helping patients identify problems and areas
of change.
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7.
8.
Helping patients develop and improve
problemsolving ability and develop recovery
coping skills.
Facilitating pharmacotherapy evaluation and
compliance. (This requires close
collaboration with the team psychiatrist.)
1.4 Agent of Change
The DDRC model assumes that change may
occur as a result of the patient-counselor
relationship and the team relationship (i.e.,
counselor, psychiatrist, psychologist, nurse, or
other professionals such as case manager or
family therapist). A positive therapeutic alliance is
seen as critical in helping patients become
involved and stay involved in the recovery
process. Community support systems,
professional treatment groups, and self-help
programs also serve as possible agents of positive
change for dually diagnosed patients. For the
more chronically and persistently mentally ill
patients, a case manager may also function as an
important agent in the change process.
Although patients have to work on a number of
intrapersonal and interpersonal issues as part of
long-term recovery, medications can facilitate this
process by attenuating acute symptoms, improving
mood, or improving cognitive abilities or impulse
control. Thus, medications may eliminate or
reduce symptoms as well as help patients become
more able to address problems during counseling
sessions. A severely depressed patient may be
unable to focus on learning cognitive or behavioral
interventions until he or she experiences a certain
degree of remission from symptoms of depression;
a floridly psychotic patient will not be able to focus
on abstinence from drugs until the psychotic
symptoms are under control.
1.5 Conception of Drug Abuse/ Addiction,
Causative Factors
Both psychiatric and addictive illnesses are
viewed as biopsychosocial disorders. These
disorders or diseases are caused or maintained by
a variety of biological, psychological, and
cultural/social factors. The degree of influence of
specific factors may vary among psychiatric
disorders.
This DDRC model assumes that there are several
possible relationships between psychiatric illness
and addiction (Daley et al. 1993; Meyer 1986).
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1. Axis I and Axis II psychopathology may
serve as a risk factor for addictive disorders
(e.g., the odds of having an addictive disorder
among individuals with a mental illness is 2.7
according to the National Institute of Mental
Health’s Epidemiologic Catchment Area
[ECA] survey).
2. Some psychiatric patients may be more
vulnerable than others to the adverse effects
of alcohol or other drugs.
3. Addiction may serve as a risk factor for
psychiatric illness (e.g., the odds of having a
psychiatric disorder among those with a drug
use disorder is 4.5 according to the ECA
survey).
4. The use of drugs can precipitate an
underlying psychiatric condition (e.g., PCP or
cocaine use may trigger a first manic episode
in a vulnerable individual).
5. Psychopathology may modify the course of
an addictive disorder in terms of:
a. Rapidity of course (earlier age
depressives experience addi
ction
problems earlier; male-limited alcoholics
[25 percent] with antisocial behaviors
have earlier onset of addiction compared
with milieu-limited alcoholics [Cloninger
1987]).
b. Response to treatment (patients with
antisocial or borderline personality
disorder often drop out of treatment
early).
c. Symptom picture and long-term outcome
(high psychiatric severity patients as
measured by the Addiction Severity Index
(ASI) do worse than low psychiatric
severity patients; there is a strong
association between relapse and
psychiatric impairment among opiate
addicts and some association between
relapse and psychiatric impairment among
alcoholics [Catalano et al. 1988; McLellan
et al. 1985]).
6. Psychiatric symptoms may develop in the
course of chronic intoxications (e.g.,
psychosis may follow PCP use or chronic
stimulant use; suicidal tendencies and
depression may follow a cocaine crash).
7. Psychiatric symptoms may emerge as a
consequence of chronic use of drugs or a
relapse (e.g., depression may be caused by
an awareness of the losses associated with
addiction; depression may follow a drug or
alcohol relapse).
8. Drug-using behavior and psychopathological
symptoms (whether antecedent or
consequent) will become meaningfully linked
over the course of time.
9. The addictive disorder and the psychiatric
disorder can develop at different points in
time and not be linked (e.g., a bipolar patient
may become hooked on drugs years after
being stable from a manic disorder; an
alcoholic may develop panic disorder or major
depression long after being sober).
10. Symptoms of one disorder can contribute to
relapse of the other disorder (e.g., increased
anxiety or hallucinations may lead the patient
to alcohol or other drug use to ameliorate
symptoms; a cocaine or alcohol binge may
lead to depressive symptoms).
2. CONTRAST TO OTHER COUNSELING
APPROACHES
2.1 Most Similar Counseling Approaches
The DDRC model is most similar to various
aspects of several models of treatment used in
addiction counseling, mental health counseling, or
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both. These include individual and group addiction
recovery models, the psychoeducational (PE)
model, the relapse prevention (RP) model, the
cognitive-behavioral model, and the interpersonal
model.
2.2 Most Dissimilar Counseling
Approaches
The DDRC model is dissimilar to the various
forms of dynamic therapies.
3. FORMAT
3.1 Modalities of Treatment
The DDRC model can be used in a variety
of group treatments and in individual treatment. It
can also be adapted to family treatment.
3.2 Ideal Treatment Setting
The DDRC model was primarily developed
for use in a mental health or dual disorders
treatment setting. It can be used throughout the
continuum of care in inpatient, other residential,
partial hospital, and outpatient settings. The
specific areas of focus will depend on each
patient’s presenting problems and symptoms and
the treatment setting. Certain aspects of this
model could be adapted and used in addiction
treatment settings provided that appropriate
training, supervision, and consultation are available
for the counselor.
3.3 Duration of Treatment
Acute inpatient dual-diagnosis treatment
usually lasts up to 3 weeks. Longer term specialty
residential treatment programs may last from
several months to a year or more. Partial
hospitalization programs usually last from 6 to
12 months. Outpatient treatment lasts 6 months or
longer. Recurrent conditions, such as certain
depressive disorders and bipolar illness, as well as
persistent mental illness such as schizophrenia,
typically require ongoing participation in
maintenance pharmacotherapy and some type of
supportive counseling.
3.4 Compatibility With Other Treatments
The DDRC model is very compatible with
pharmacotherapy and family treatment. Many
patients require medication to treat psychiatric
symptoms. Therefore, medication compliance, the
perception of taking medications as a recovering
alcoholic or addict, and potential adverse effects
of alcohol or other drugs on medication efficacy
are important issues to discuss with the patient.
Family participation in assessment and treatment
is viewed as important and compatible with the
DDRC model. The family can:
1. Help provide important information in the
assessment process.
2. Provide support to the recovering patient.
3. Address their own questions, concerns, and
reactions to coping with the dually diagnosed
patient.
4. Address their own problems and issues in
treatment sessions or self-help programs.
5. Help identify early signs of addiction relapse
or psychiatric recurrence and point these out
to the recovering dually diagnosed family
member.
A combination of family PE programs, family
counseling sessions, and family support programs
can be used to help families. Referrals for
assessment of serious problems (psychiatric, drug
abuse, behavioral) among specific family members
can also be initiated as necessary (e.g., a child of
a patient who is suicidal, very depressed, or
getting into trouble at school can be referred for a
psychiatric evaluation).
3.5 Role of Self-Help Programs
Self-help programs are very important in the
DDRC model of treatment. All patients are
educated regarding self-help programs and linked
up to specific programs. The self-help programs
recommended may include any of the following
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for a given patient: AA, NA, CA, and other
addiction support groups such as RR or Women
for Sobriety; dual-recovery support groups; and
mental health support groups. However, this
model does not assume that a patient cannot
recover without involvement in a 12-step group or
that failure to attend 12-step groups is a sign of
resistance. The DDRC model also assumes that
some patients may use some of the tools of
recovery of self-help programs even if they do not
attend meetings. Sponsorship, recovery literature,
slogans, and recovery clubs are also seen as very
helpful aspects of recovery for dually diagnosed
patients.
4. COUNSELOR CHARACTERISTICS
AND TRAINING
4.1 Educational Requirements
The educational requirements are variable for
inpatient staff and depend on the professional
discipline’s requirements. Formal education of
inpatient staff include M.D., Ph.D., master’s,
bachelor’s, and associate degrees. Training in
fields such as nursing may vary as well and
include M.S.N., B.S.N., R.N., and L.P.N.
Outpatient therapists tend to have at least a
master’s degree or higher and function more
autonomously than inpatient staff.
4.2 Training, Credentials, and Experience
Required
To effectively provide counseling services to
dually diagnosed patients, the counselor needs to
have a broad knowledge of assessment and
treatment of dual disorders. Specific areas with
which the counselor should be familiar, at a
minimum, include the following:
1. Psychiatric illnesses (types, causes,
symptoms, and effects).
2. Drug use disorders (trends in drug abuse;
types and effects of various drugs; causes,
symptoms, and effects of addiction).
3. The relationship between the psychiatric
illness and drug use.
4. The recovery process for dual disorders.
5. Self-help programs (for addiction, mental
health disorders, and dual disorders).
6. Family issues in treatment and recovery.
7. Relapse (precipitants, warning signs, and RP
strategies for both disorders).
8. Specialized psychosocial treatment
approaches for various psychiatric disorders
(e.g., treatments for posttraumatic stress
disorder, obsessive-compulsive disorder).
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