ABSTRACT
Although a number of case series and randomised controlled trials have demonstrated that individual cognitive behaviour therapy (CBT) can produce clinically significant outcomes for patients with chronic psychosis (Kuipers et al., 1998; Tarrier et al., 1997, 1998), little attention has been paid to those patients who have co-existing problems of psychosis and substance use, despite reported estimates of the incidence of substance use problems being as high as 60% (Lehman & Dixon, 1995). Indeed, many researchers have either excluded those who have substance use problems from CBT studies, or, the needs of those included with substance use problems have been ignored. Furthermore, the efficacy of antipsychotic drugs in this population is, technically, unknown, because dual diagnosis is routinely an exclusion criterion from efficacy trials (Meuser & Lewis, in press). This may be partly related to the way services have been organised. Traditionally, services for people with mental health problems such as schizophrenia and those for substance use problems have been independent from each other and have tended to adopt differing treatment philosophies. For example, substance use services tend to emphasise that “recovery” is a possible outcome, whereas mental health services tend to view severe mental health problems within a rehabilitation framework, where the illness is viewed as having a long-term chronic course. Although these rationales make sense for the disorders that they are representing, when a patient presents with co-existing difficulties, clinicians are faced with a dilemma about which service will meet the needs of the client. In addition, generally, staff are not trained or experienced in the skills necessary to manage both disorders leading to patients receiving inadequate help for one aspect of their difficulties and staff feeling unskilled because they cannot provide the appropriate help for the patient.
