Behavioral Treatment for Substance Abuse in People with Serious and Persistent Mental Illness: A Handbook for Mental Health Professionals

Studies of both community and clinical populations have repeatedly shown that many individuals with severe mental illness have co-occurring substance use disorders. Since the early 1990s, numerous authors have advocated the use of “integrated treatment” for patients with these two disorders. The term integrated treatment, however, has been defined in many different ways. If one were to survey substance abuse treatment program directors about their treatment approach with patients with co-occurring psychiatric illness, they would virtually all state that they deliver integrated treatment. However, they would be delivering quite different treatments. That is because there is no single, gold-standard definition of integrated treatment.

Allan Bellack, Ph.D., along with his colleagues Melanie Bennett, Ph.D., and Jean Gearon, Ph.D., have developed a model of integrated treatment entitled Behavioral Treatment for Substance Abuse in Schizophrenia (BTSAS), which they have broadened and re-titled to include individuals with bipolar disorder and other serious mental illnesses. Their handbook is a beautifully written, clearly delineated, user-friendly description of their treatment model.

BTSAS is a small-group (i.e., 4 to 6 participants) treatment approach that focuses specifically on substance use. Its six major components include 1) motivational interviewing to increase motivation to address substance use issues; 2) structured goal-setting regarding substance use; 3) a urinalysis contingency program, in which patients are reinforced for reductions in substance use; 4) social skills and drug refusal training; 5) education about both reasons for and consequences of substance use, with a goal of enhancing motivation to reduce or stop use; and 6) behaviorally-oriented relapse prevention training. A chapter is devoted to each specific topic in this book.

This book includes all of the core elements that one would hope for in a treatment manual: why, what, how, and what if. An excellent theoretical background section discusses the extent of the problem of substance use disorder-psychiatric illness comorbidity and reviews the ways that others have tried to address it. The theoretical underpinnings of BTSAS are discussed, along with the solid empirical evidence supporting its efficacy. The greatest strength of the manual is in the “how” and “what if” sections. The reader (perhaps a prospective therapist) is taught step-by-step how to prepare to conduct BTSAS and how to set up and run a BTSAS program. Groups are reviewed session-by-session. Skill sheets (e.g., making small talk, coping with depression and stress) are provided, along with outlines for conducting each session. Ample clinical examples are given, in which the therapist is instructed quite concretely about what to say throughout the group session. Common clinical problems are discussed, along with potential ways to deal with them. Indeed, an entire chapter is devoted to this topic; the therapist is advised on dealing with issues such as poor attendance, continued drug use, and crises such as loss of housing.

Dr. Bellack and his colleagues are clearly highly experienced with this population. They blend academic expertise with real-world experience in a way that enables the reader to benefit enormously from this manual, whether conducting BTSAS per se or working with this patient population in another treatment setting. This book is an excellent guide for both beginning and experienced clinicians working with seriously mentally ill patients. While many clinicians may have previously had difficulty knowing exactly how to address substance use in this patient population, this book will help them enormously to address this vexing and clinically important problem.