NADD Bulletin Volume III Number 4 Article 3

Complete listing

“3D” Unified Group Process for the Treatment of Triply Diagnosed Persons

Marina Harris, MA, LPA; Rosemary Edwardson, MA, LPC


Although chemical dependence carries special risk factors for persons with cognitive deficits-as well as special treatment needs-problems of addiction have only recently been recognized as a serious threat to the health and well-being of persons with developmental disability. Access to services and the specialized adaptation of treatment have, thus far, been slow to emerge.

In the 1990’s, however, we witnessed a call to action. Tomasulo (1998) writes, “The combination of cognitive limitations, developmental delay, and psychiatric involvement creates a need for a different approach.” Developmentally disabled persons with multiple treatment needs are now recognized as being at great risk-inadequately treated and underserved-and as more than simply “falling through the cracks.” “The gulf between the methods and philosophies of service delivery systems for people with mental retardation and addiction . . . might be described better as a chasm than a crack and the consequences can indeed be dire for people who fall into this abyss” (Ruf, 1999).

Triply diagnosed individuals-persons who have needs in the three areas of developmental disability, mental illness, and substance abuse-pose considerable challenge to service delivery systems. This “3D” challenge, while considerable, is not insurmountable. This article demonstrates some solutions for improving treatment effectiveness through unified group process.

Incidence and Risk

Early reports of near-average or lower than average incidence have been mistakenly interpreted as a reduced need for substance abuse services. Most studies prior to this decade suggested that problems of addiction occurred among persons with developmental disability at a lower percentage rate than that estimated for the general community. Edgerton (1986), following a long-term-ethnographic study, concluded that persons with mental retardation living in the community used substances less often than their non-retarded parents, friends, siblings, and spouses. He attributed this low incidence to positive socialization, low income, and the expense of buying alcohol and other drugs. A follow-up study involving deinstitutionalized persons with retardation (McCarver & Craig, 1988) determined that the heavy use of alcohol or other drugs among this population occurred, but was infrequent. Reviews of psychiatric disorders among the DD population as recent as 1986 made little or no reference to substance use disorders (Clarke, Clark & Berg, 1986; Stavrakaki, 1986).

The detection of substance abuse by early investigators appears to have been impeded by misconceptions concerning the nature of substance abuse and a limited awareness of risk factors unique to persons with developmental disability. Substance use need not be heavy or frequent to constitute abuse. In combination with developmental disability or mental illness, drugs and alcohol can have serious consequences. These preexisting neurological challenges magnify risk. Any use-even at a level considered “socially acceptable”-can constitute abuse (Hrynewych & Nagy, 1998). For the multiply diagnosed client, progression from experimental or social use on through the various stages of dependence can be rapid. Negative consequences-financial and sexual exploitation, legal difficulties, and further compromise to cognitive function-can accumulate quickly.

Risks and vulnerabilities appear to expand geometrically with the addition of each new diagnostic category-as do challenges for the clinicians and programs attempting to develop effective treatments. Dually and triply diagnosed persons-representing various combinations of mental illness, substance abuse, and developmental disability-continue to be at risk of ‘falling into an abyss’ comprised of alienation, unemployment, homelessness, incarceration, and premature death.

Recent studies suggest not only a higher (possibly increasing) incidence of substance abuse among the DD populace, but also a significantly greater than average need for treatment. Westermeyer, Kemp, and Nugent (1996) found that, among a sample of 642 persons receiving substance abuse treatment at two university-affiliated clinics, persons with mental retardation constituted 6.2% of the sample-more than twice the general MR population constituent of 1-3%. Over-representation in this sample may be best understood through an examination of the characteristics of persons who have developmental disability and addiction-related problems.

In a matched comparison study of 40 persons with mild mental retardation and substance abuse and a control group of 40 individuals with mild mental retardation but no substance abuse, Westermeyer, Phaobtong, and Neider (1988) found that substance abuse was associated with significantly higher need for psychiatric, medical, and surgical treatment. Family histories of substance abuse and pathogenic childhood factors were also significantly higher in the substance abuse group. Exposure to substances began earlier in life, and-perhaps the most significant finding-problems of addiction occurred even with lower doses and less frequent usage compared to non-retarded correlates. The greater risk of addiction and the speed with which negative effects can accrue among persons with neurological, psychological, or biochemical challenges, as with many persons with developmental disability, is well documented (Shawn & Spence, 1985; Rivinus, 1988), yet it is often overlooked.

Availability and social pressure, factors associated with drug abuse among the general population, can be compounded by developmental crises specific to the DD population. The adult with mild or moderate mental retardation can be viewed as having a protracted adolescence, in that he or she generally must struggle over an extended period of time in order to gain independence from parents and other caretakers. Negative self-perceptions and problems with social acceptance are often associated with this struggle-as are low self-esteem, loneliness, rebellion, depression, or defeatism-any of which can also contribute to, or perpetuate, substance abuse. Often vulnerable and suggestible, the person with developmental disability is an easy target for exploitation. He or she may become involved in criminal activities in order to obtain funds for purchasing alcohol and drugs for family, friends, or self.

Denial, misunderstanding, and masking combine to produce what are perhaps the greatest risks for this special population-being overlooked or misdiagnosed. Many of the symptoms of intoxication-labile affect, slurred speech, impaired judgement, an awkward or unsteady gait-can also represent everyday challenges associated with developmental disability. The fact that substance abuse mimics a wide range of mental illnesses-from anxiety and mood disorders to psychoses-further complicates diagnosis and the determination of appropriate treatment.

Factors Influencing Effective Treatment

Westermeyer et al. (1996) and Evans (1983) describe how additional barriers to effective treatment of the multiply diagnosed individual arise, ironically, through clinical specialization. Staff accustomed to providing developmental disability services may not recognize substance abuse or have the skills and training necessary to treat it. Similarly, substance abuse treatment specialists may have little exposure to the concepts or techniques necessary for understanding developmental disability. Cross-training and collaboration are essential in providing services for the multiply challenged individual.

Normalization and mainstreaming, although highly desirable in many other contexts, is not usually effective for treating substance abusing persons who have developmental disability (Brady, 1993). Attempts at mainstreaming have been associated with an array of problems including: difficulty understanding the materials and ideas presented; trouble keeping up; being variously stigmatized, resented, or over-protected by fellow participants; and, ultimately, to negative treatment effects such as heightened shame and decreased motivation for achieving or maintaining sobriety (Cattan & Grossman, 1995; Annand & Ruf, 1998).

Unified Group Process

Group therapy has emerged as the most effective treatment modality for this population (Cattan & Grossman, 1995). Group participation promotes feelings of acceptance and belonging. It provides a format for sharing support and encouragement and for receiving feedback from peers facing similar challenges. Co-facilitators can share expertise and, through their collaboration, minimize burnout. Treatment simultaneously addresses all three domains. The central focus is recovery, but mental health and developmental disability needs are also incorporated. Piecemeal approaches are costly and lead to fragmentation and confusion. Revolving door effects emerge as participants become disenchanted. The integrated “3D” group offers the hope of increasing both consumer and clinician satisfactions while increasing treatment effectiveness. It also provides an arena for refining and adapting techniques.

Techniques that have emerged as beneficial in this process include gentle confrontation, tangible symbols, rituals, supported socialization, and participant-centeredness. Confrontation is used to increase awareness and expectation without shaming or demanding. This can be initiated by facilitators or participants. Tangible symbols provide concrete, even interactive, mnemonic devices for recalling information necessary to counter real-life challenges to sobriety. Ritual imparts comfort through repetition and predictability; it creates a safe venue for practicing new skills, new and safe ways to be with others. Group activities, even breaks, can be designed to promote positive interaction among participants-as an antidote to too-often chronic loneliness and despair. Sessions can respond directly to participants’ needs, using ideas and interests generated by the participants themselves. A situation encountered between meetings by one participant can be the focus of group problem-solving and feedback-an opportunity for all to share related challenges-and a springboard for facilitators to subtly interweave information and insights essential to recovery.


Group therapy for the triply diagnosed person is a nurturing, directive milieu. Simplification and repetition, gentle firmness and respect, are utilized in imparting to participants the tools they need for recovery. It is a long-term process that instills hope and comfort but does not rescue.

As we move toward the next millennium-and as persons with mental illness and development disability become well integrated into our communities-their risk of substance abuse appears also to increase. The triple threat of “3D” is one we can no longer ignore.


Annand, G. N. & Ruf, G. (1998). Overcoming barriers to effective treatment for persons with mental retardation and substance abuse problems. NADD Bulletin, 1, 2.

Brady, K. (1993). Substance abuse in the dually diagnosed. NADD Newsletter, 10, 5.

Cattan, L. S. & Grossman, P. L. (1995). Drunk, disabled, and mentally ill: A collaborative treatment model. Conference Proceedings, NADD 12th Annual Conference. Kingston, NY: NADD Press.

Clarke, A. M., Clark, A. D. B., & Berg, J. M. (1986). Mental retardation: The changing outlook. New York: Free Press.

Edgerton, R. B. (1986). Alcohol and drug use by mentally retarded adults. American Journal of Mental Deficiency, 90, 602-609.

Evans, D. P. (1983). The lives of mentally retarded people. Boulder, CO: Westview Press.

Hrynewych, B. & Nagy, P. (1998, May). Working with the substance abusing, mentally ill, mentally retarded client. Paper presented at conference, Charlotte Area Health Education Center/Duke University Medical Center, Gastonia, NC.

McCarver, R. B. & Craig, E. M. (1988). Placement of the retarded in the community: Prognosis and outcome. In N. R. Ellis (Ed.), International Review of Research in Mental Retardation. New York: Academic Press.

Rivinus, T. (1988). Alcohol use in mentally retarded persons. Psychiatric Aspects of Mental Retardation, 7, 151-56.

Ruf, G. (1999). Addiction treatment for people with mental retardation and learning disabilities: Why we need specialized services. NADD Bulletin, 2, 47-53.

Shawn, G. K. & Spence, M. (1985). Psychological impairment in alcoholism. Alcoholics Anonymous, 20, 243-249.

Stavrakaki, C. (1986). Psychiatric aspects of mental retardation. Psychiatric Clinics of North America, 9, 591-603.

Tomasulo, D. J. (1998). Drug abuse treatment for people with mental retardation: Who will do it? Mental Health Aspects of Developmental Disabilities, 1.

Westermeyer, J., Kemp, K., & Nugent, S. (1996). Substance disorder among persons with mild mental retardation. The American Journal of Addiction, 5, 37-55.

Westermeyer, J., Phaobtong, T., & Neider, J. (1988). Substance use and abuse among mentally retarded persons: A comparison of patients and a survey population. American Journal of Drug and Alcohol Abuse, 14, 109-123.

For further information:

Marina Harris
Gaston-Lincoln DD/Support, SVCS
708 S. Chestnut Street
Gastonia, NC 28054
(704) 854-4840