A Twist on Dual Diagnosis

Clinical Psychiatry News - Volume 33, Issue 1, Page 30 (January 2005)

Now that we are solidly in the 21st century and know the real health effects of cigarette smoking, we psychiatrists should be actively participating in smoking prevention and smoking-cessation treatments.

As medical doctors, we need to change the way we define dual-diagnosis illnesses. Why not consider the dual diagnosis of cigarette smoking and pulmonary disease—or cigarette smoking and cardiac illness—as examples of such illnesses?

The one good thing about smoking is that it is an entirely preventable cause of death, according to Elizabeth M. Whelan, Sc.D., founder and president of the American Council on Science and Health in New York, and a public health expert on cigarette smoking and disease. In her submission on cigarettes as the major preventable cause of premature death in the case of Anderson v. American Tobacco Co. et. al., Dr. Whelan pointed out that as far back as 1984, the American Thoracic Society made smoking the major preventable cause of death and disability in the developed world. Today, of the 2 million total deaths in the United States each year, 450,000 deaths—a full 25%—are directly related to smoking, according to Dr. Whelan. Tobacco use is such a severe public health problem that more than 1 billion people eventually will be killed worldwide by the effects of smoking. This is about one-fifth of all people now living in developed countries, Dr. Whelan wrote.

In my first few years at New York University/Bellevue Hospital Center, I developed one of the earliest smoking-cessation programs in a county hospital. Although it later evolved into the short-term psychotherapy program, smoking cessation was always a major part of its didactic and clinical mission. To help patients quit smoking, I developed my learning, philosophizing, and action (LPA) technique. This cognitive-dialectical approach works not only for short-term psychotherapy but also for habit control. This is how the technique worked with smokers:

? Learning Phase. In this phase, the patient and I discussed the statistics of smoking-related illnesses, such as cancer, heart disease, and pulmonary illnesses. Using the best available knowledge, I helped the patient understand the extent to which smoking was causing severe physiologic damage. I also used this phase to answer any questions the patient had. We explored the positive effects that smoking cessation would yield. As is the case today, the most dramatic results were usually obtained in the area of cardiac health.

? Philosophy Phase. We discussed how the smoking habit had become an addiction and had essentially taken on a life of its own. Whether the habit originated because of peer pressure, as a result of learned behaviors within the family, or through the powerful world of advertising, it had become solidified within the patient's life.

The concepts of addiction and habituation also were explored in this phase. I pointed out that the physical addiction to nicotine is finite in terms of the physical cravings that occur when the patient gives up smoking, and that these cravings disappear in a relatively short time. I also explained that habituation is more psychological than physical, and is linked to behavioral patterns that center around the lighting and smoking of a cigarette, such as always lighting up when talking on the telephone.

The behavioral aspects of cigarette smoking can become so integrated into a patient's lifestyle that they appear to endure longer than the chemical/physiologic addiction to nicotine. These philosophical discussions were critical, because they provided a real—and, from my point of view, desirable—psychological/psychiatric touch to the entire approach. In other words, as the patient learned maladaptive behaviors or lifestyles, he or she also developed habituations that, in the case of smoking, led to addiction.

? Action Phase. This phase took the form of rethinking the habit or addiction. Much of the smoking-cessation therapy that I do centers on my patients' ability to rethink priorities in their lives. In the case of smokers, a cognitive-dialectic approach, leading to a focus on the positive aspects of the patient's life, is important.

In this action phase, patients are asked to think or rethink how they can take charge of a habit or an addiction that they no longer want. The key is for patients to take charge of one habit in their lives by realizing that they are in charge of it rather than that the habit is in charge of them.

In smoking-cessation treatment, the reward for success is great, and most patients seem to be able to see that clearly. The important reward here lies not only stopping the smoking but also in taking personal control of one's life. When I talk with patients, I like to illustrate the idea of control with the example of bringing something to a dry cleaner and expecting it to be back on a certain day. Not getting the item back on that day—which happens to many of us—demonstrates that in many areas of life, we are not in control. When it comes to a personal commitment to stop the smoking habit, however, the patient becomes the “boss” and can be in control.

Many models demonstrate how a lack of control affects our daily lives. As psychiatrists, we can develop different examples to illustrate this reality. But the key is getting patients to take control of their lives in one specific area—smoking cessation—and to derive a good feeling from ridding themselves of a habit or unwanted addiction. This approach reinforces the patient's self-esteem, which, in turn, becomes a significant part of the success.

The treatment program that I used lasted from one to three visits. It was efficient, cost effective, and dynamic enough to keep the patient from dropping out. More extensive programs can be helpful if they are focused and show success. Ongoing support groups also have been effective, as have hypnosis and behavior modification therapies. Enabling patients to understand what smoking means to them from the traditional psychoanalytical perspective is fine, but will such explorations get the patient to stop smoking?

As experts in human behavior, we psychiatrists have the skills to prevent or treat a habit or an addiction that is catastrophic in terms of human suffering. Instead, we have left such interventions to nonmedical programs like Smokenders.

In addition, no primary care physician who conducts physical exams should give a clean bill of health to a patient who smokes cigarettes. Regardless of how good the physical findings might appear, physical damage is being done to multiple bodily systems—and pathology exists.

Of the millions of patients psychiatrists see, how many are asked to give a smoking history, let alone participate in a treatment program? Medication management is an important part of psychiatric care, but we also need to get back into the talk therapies.

Smoking-cessation strategies are a good first step to getting back into talking with patients at a sophisticated level, embracing the newer concepts of dual diagnosis. We must help our patients to understand the connections between smoking and the physical illnesses that result.

Let me hear about your strategies with habit control by e-mailing me at cpnews@elsevier.com, and I'll try to pass them along to my readers.

PII: S0270-6644(05)70260-5

doi:10.1016/S0270-6644(05)70260-5